Frequency of same day discharge and its feasibility after transradial percutaneous coronary intervention

To observe the frequency of same day discharge and its feasibility after transradial percutaneous coronary intervention [PCI]. This study was conducted at the Coronary Care Unit and Angiography ward of the Punjab Institute of Cardiology, Lahore from January 2007 to June 2007. Non-probability purposive sampling technique was used to enroll 100 subjects. A total of 790 PCIs were performed from January 2007 to June 2007 at the Punjab Institute of Cardiology, Lahore via transradial approach. Out of these 790 patients, one hundred patients [12.66%] had same-day discharge after transradial PCI. These patients were evaluated and information was obtained regarding entry site complications and adverse cardiovascular events at the time of discharge and at one month follow up after the procedure. Out of 100 patients, who had same day discharge, 2[2%] patients had hematoma at the time of discharge, 1[1%] had asymptomatic loss of radial pulse and 6[6%] patients had weak but palpable radial artery. At one month follow up 4[4%] patients had asymptomatic loss of radial pulse. However, none of these patients had major access site complications which required blood transfusion or admission to the hospital. Only 1[1%] patient had repeat coronary angiogram for chest pain, which revealed patent stent and TIMI III flow in distal vessel. One patient had repeat PCI but it was done to another vessel and previously placed stent was patent. There was no death and none of the patients underwent coronary artery bypass grafting [CABG]. The radial artery is the route of choice for most coronary procedures. The radial approach virtually eliminates access site complications after PCI, and allows rapid mobilization of the patient. Same-day discharge after radial PCI is a safe and feasible strategy

Clinical outcome of double valve repalcement with or without small aortic prosthesis

To determine the effect of aortic prosthesis size on clinical outcome of patients undergoing double cardiac valve replacement [DVR]. A quasi-experimental study. Cardiac Surgery Department, Punjab Institute of Cardiology, Lahore, Pakistan, from February 1996 to December 2008. One hundred and forty patients undergoing double cardiac valve replacement were divided into 2 groups. Group I, 75 [53.6%] receiving aortic prosthesis size of /= 21 mm size. All patients were prospectively followed-up for 12 years in order to study mortality and valve related complications. There were 94 males [67.1%] and 46 females [32.9%] with a mean age of 25.5 +/- 10 years. In Group I, 21 patients [28%] had aortic valve replacement [AVR] with 19 mm valve size and 54 patients [72%] had 21 mm size valves implanted. In Group II, 39 patients [60%] had AVR with 23 mm size valves implanted followed by 16 [24.6%] who received 25 mm size valves. Posterior mitral leaflet was preserved in 15 patients [20%] in Group I and 14 [21.5%] in Group II. Mortality was seen in 13 patients [9.3%]; of these 5 [3.6%] were in Group I and 8 [5.7%] were in Group II. Nine patients [6.4%] had incomplete follow-up [In Group I, 2 patients died in ICU, 2 died within 30 days of admission and one was a late death. In Group II, 1 patient died in ICU, 1 within 30 days of admission and 6 within 1 year of operation]. Double valve replacement with implantation of small aortic prosthesis has similar overall mortality as compared to patients having larger sized aortic valves

Outcome of double vs. single valve replacement for rheumatic heart disease

To compare the follow-up results of double valve replacement [DVR] i.e. mitral valve replacement [MVR] and aortic valve replacement [AVR] vs. isolated MVR or AVR for rheumatic heart disease. An interventional qausi-experimental study. Department of Cardiac Surgery, Punjab Institute of Cardiology, Lahore, from September 1994 till December 2007. Prospective follow-up of 493 patients with mechanical heart valves was carried out using clinical assessment, international normalized ratio and echocardiography. Patients were divided into three groups: group I having MVR, group II having AVR and group III having DVR. Survival, time and causes of mortality, and frequency of valve thrombosis, haemorrhage and cerebrovascular haemorrhage was noted in the three groups and described as proportions. Actuarial survival was analyzed by Kaplan-Meier method. There were 493 with 287 [58.3%] in group I, 87 [17.6%] in group II and 119 [24.1%] in group III. Total follow-up was 2429.2 patient [pt]-years. Of 77 [15.6%] deaths, 19 [3.8%] were in-hospital and 58 [11.8%] were late. In-hospital mortality was highest 4 [4.6%] in group II followed by 5 [4.2%] group III and 10 [3.5%] group I. Late deaths were 39 [13.4%] in group I, 9 [10.2%] in group II and 10 [8.3%] in group III. The total actuarial survival was 84.4% with survival of 83%, 85.1%, 87.4% in groups I, II and III respectively. On follow-up valve thrombosis occurred in 12 [0.49%/pt-years] patients; 9 [0.67%/pt-years] group I, 1 [0.22%/pt-years] in group II and 2 [0.31%/pt-years] in group III. Severe haemorrhage occurred in 19 [0.78%/pt-years]; 14 in [1.04%/pt-years] in group I, 3 [0.66%/pt-years] group II and 2 [0.31%/pt-years] in group III. Cerebrovascular accidents occurred in 34 [1.3%/pt-years]; 26 [1.95%/pt-years] in group I and 4 in groups II [0.89%/pt-years] and III [0.62%/pt-years] each. In patients with rheumatic heart disease having combined mitral and aortic valve disease DVR should be performed whenever indicated as it has similar in-hospital mortality and better late survival as compared to isolated aortic or mitral valve replacement

Myocardial infarction; clinical predictors of in hospital complications in patients presenting with acute st segment elevation

To determine clinical predictors of in-hospital complications in patients presenting with acute ST elevation myocardial infarction. Descriptive Study. from October 2010 to January 2011. Faisalabad Institute of CardioIogy Faisalabad. A total 342 patients with AMI were recruited in this study. All patients presenting with acute ST elevation myocardial infarction and fulfilling inclusion and exclusion criteria were included in the study. A full history was taken, particularly age, sex occupation, address, history of smoking, diabetes mellitus, hypertension, ischemic heart disease and family history of ischemic heart diseases Primary end point was death while secondary end point were patients who had mechanical, ischemic or electrical complications or all of them Mean age of the study population was 56.3 +/- 12.7 years. There were 255[74.6%] males and 87[25.4%] females. There were 103[30.1%] diabetics, 137[40.1%] hypertensive and 174[50.9%] smokers. Family history of IHD was present in 34[9.9%]. Obesity was observed in 60[17.5%]. Dyslipidemia was observed in 45[13.2%]. Majority of patients 123[36%] presented between 4-8 hours after the onset of symptoms. Only 72[21.1%] patients presented to the hospital within 4 hours of onset of symptoms. Overall 194[56.7%] patients had anterior wall myocardial infarction followed by Inferior wall myocardial infarction 84[24.6%] patients. Streptokinase therapy for thrombolysis was given to 236[69%] patients. Overall in-hospital mortality was 28[8.2%]. Most frequent in-hospital complication was cardiogenic shock occurring in 38[11.1%] followed by lschemic complications [Post Ml angina and Re-MI] 37[10.8%], heart failure in 37[10.8%] and 1[st] and 2[nd] degree AV blocks in 36[10.5%] patients. In-hospital mortality was most significantly associated with site of Ml i.e. anterior wall myocardial infarction [X[2]=28.88, p=0.0001] followed by patients not receiving Streptokinase therapy [X[2]=18, p=0.001], Age [X[2]=10.13, p=0.006]. Site of Ml had the highest Contingency Coefficient value of 0.279 followed by Streptokinase therapy 0.195 and age 0.170. Cardiogenic shock was the most frequent complication. Major predictors of in-hospital mortality were anterior wall myocardial infarction, patients not receiving streptokinase therapy and old age

Triggering of acute coronary syndromes by physical exertion and anger

Objectives: To assess the role of vigorous physical exertion and anger as triggers of acute coronary syndromes [ACS]

Materials And Methods: This prospective observational study was conducted at the Punjab Institute of Cardiology, Lahore from April to September 2010. Two hundred patients admitted through emergency and out patient department were studied. Patients were questioned in detail about the circumstances surrounding the onset of acute symptoms. Anger was assessed according to the anger scale comprising of 7 points and physical activity was assessed according to activity scale also comprising of 7 points

Results: The mean age of the study population was 54.2 +/- 10.8 years. There were 149[74.5%] males and 51[25.5%] females. Diabetes mellitus occurred in 69[34.5%], hypertension 86[43%], smoking 71[35.5%] and dyslipidemia in 51[25.5%] patients. Majority of patients had low education status with primary education in 75[37.5%] and illiteracy in 74[37%] patients. Premonitory symptoms occurred in 92[46%] patients. Most patients 65[32.5%] presented to the hospital in 6-12 hours duration of onset of symptoms followed by 54[27%] patients presenting in 0-6 hours. Typical chest pain occurred in 166[83%] patients. Mostly patients 123[61.5%] had ST segment elevation myocardial infarction, followed by Non ST segment elevation myocardial infarction in 45[22.5%] and unstable angina in 31[15.5%] patients. The onset anger scale identified 25[12.5%] patients having associated anger at the time of onset of symptoms. According to anger scale, level 1 anger was observed in 5[2.5%], level 3 in 3[1.5%], level 4 in 4[2%], level 5 in 5[2.5%], level 6 in 6[3%] and level 7 in 2[1%] patients. The history of exertion at the time of onset of symptoms revealed that 95[47.5%] patients had level 1 exertion followed by level 2 exertion in 61[30.5%] and level 4 exertion in 14[7%] patients

Conclusion: This study confirms previous results and shows a graded exposure- response relationship between physical exertion intensity and triggering of AMI onset. The specific clinical and sociodemographic factors associated with physical exertion and anger suggest that different pathophysiological processes may be involved

Carotid disease in diabetic patients undergoing coronary artery bypass grafting

Objective: To compare the severity of carotid artery disease in diabetic and non-diabetic patients undergoing coronary artery bypass grafting. Methods: From January to June 2008, 379 patients undergoing elective coronary artery bypass surgery were preoperatively evaluated for the presence of carotid stenoses by duplex scanning. Patients were divided into two groups, Group I, 156 [41.2%] diabetic patients and Group II, 223 [58.8%] non-diabetic patients. Results: There were 314 [82.8%] males and 65 [17.2%] females with a mean age of 57.2 +/- 9.1 years. In diabetic group there were 125 [80.1%] males and 31 [19.9%] females with a mean age of 56.3 +/- 8.9 years. Left main stem stenosis was present in 59 [37.8%] diabetics and 45 [20.2%] non-diabetics [p<0.0001]. Diffuse disease in left anterior descending [LAD] artery was observed in more diabetic patients 72 [46.2%] as compared to non-diabetics 83 [37.2%] [p<0.295]. Single tight stenosis in LAD was observed in more non-diabetics. Significant carotid artery stenosis was observed in 50 [13.2%] patients. Carotid artery stenosis was observed in 30 [19.2%] diabetics as compared to 20 [9%] non-diabetics [p<0.004]. Analysis of percentage stenosis of carotid artery disease in the study population revealed that >70% stenosis was present in 20 [5.3%] with 13 [8.3%] diabetics and 7 [3.1%] non-diabetics [p<0.025]. Stenosis of 50– 70% was observed in 30 [7.9%] of which 17 [10.9%] were diabetics and 13 [5.8%] were non-diabetics. Conclusion: Presence of diabetes mellitus is associated with diffuse coronary artery disease and significant carotid artery disease in patients undergoing coronary artery bypass grafting

In hospital outcome of patients with acute ST-elevation myocardial infarction requiring temporary transvenous pacing

Background: Acute myocardial infarction continues to be a major public health problem worldwide. Temporary pacing is needed in various situations of myocardial infarction

Objective: To determine in hospital outcome [electrical and mechanical complications] of acute myocardial infarction [MI] patients requiring temporary transvenous pacing

Patients and Methods: This descriptive case series was conducted at the Cardiology Department of the Punjab Institute of Cardiology, Lahore from October 2007 to April 2008.One hundred patients presenting with acute chest pain consistent with acute myocardial infarction, typical ECG changes and raised serum markers of myocardial infarction and requiring temporary pacing during their hospital stay were included

Results: A total of 100 patients were included in study. The mean age of the study population was 49.9+/-7.5 years. There were 85% males and 15% females. Majority of patients 66% were smokers. Diabetes mellitus and hypertension was observed in 45% patients. Mean duration of onset of symptoms till arrival at the hospital was 8.2+/-4.6 hours. Majority of patients 65% had inferior wall myocardial infarction [IWMI], 3% patients had IWMI with right ventricular MI. Extensive anterior wall myocardial infarction [AWMI] was observed in 25%. Anteroseptal wall MI occurred in 7% of patients. Streptokinase was used for thrombolysis in 76% patients. First degree heart block was noted in 2% patients at arrival. Second degree Mobitz type 1 occurred in 1% and Mobitz type 2 in 4%. Third degree or complete heart block was noted in 31% patients. Right bundle branch block with left anterior fascicular block occurred in 3% and trifascicular block in 4%. During hospital stay, complete heart block occurred on 1[st] post MI day in 55% patients, and on 2[nd] post MI day in 3% patients. Temporary pacemaker was implanted in 40% of patients at presentation, in 57% of patients on 1[st] post MI day and in 3% on 2[nd] post MI day. In-hospital mortality occurred in 8%, ventricular tachycardia in 29%, ventricular fibrillation in 2% and asystole in 2% patients

Conclusion: Complete heart block in patients with ST-Elevation myocardial infarction requiring temporary pacing is accompanied by a worse early prognosis. A more aggressive therapeutic approach aimed to reduce early mortality seems warranted in these patients

Circadian periodicity in the onset of acute ST segment elevation

To analyze the influence of diabetes mellitus on circadian rhythm affecting the onset of acute ST elevation myocardial infarction. Observational study. February to August 2010. Faisalabad Institute of Cardiology, Faisalabad. Three hundred and seven consecutive patients who fulfilled the inclusion and exclusion criteria and presented with first MI were studied. All patients were divided into four groups according to the 6:00 hours interval of the day [Circadian rhythm]. Group I comprised of patients presenting with onset of symptoms between 0-6 hours, Group II 6:01 to 12:00 hours, Group III 12:01 to 18:00 hours and Group IV 18:01 to 24:00 hours. Data was analyzed for variations within groups. Two peaks of onset of symptoms were observed, first between 0-6 hours 144 [33.9%] patients and the second between 6:01 to 12:00 hours 87 [28.3%] and a non significant association was observed in time of onset of acute myocardial infarction P = 0.082. The trough was evening time 12:01 to 18:00 hours where only 63 [20.5%] patients had acute myocardial infarction. Mean age of study population was 56 +/- 12.7 years. Mean age was similar in all the four groups P = 0.155. There were 228 [74.3%] males, 79 [25.5%] females. The circadian morning peak of MI symptom onset was attenuated in patients with diabetes as Group IV consisted of higher number 24 [37.5%] of diabetics followed by group I 23 [34.7%]. Overall group II had the maximum number of hypertensive patients 41 [47.1%] as compared to other groups. Obesity was observed in 55 [18%] with similar number of patients in all groups P = 0.492. Majority of patients 117 [38.1%] presented between 4-8 hours after the onset of symptoms. Overall 170 [55.4%] patients had anterior wall myocardial infarction followed by inferior wall myocardial infarction in 82 [26.7%] patients. Our study demonstrates that the circadian morning peak of MI symptom onset was attenuated in patients with diabetes, suggesting a role of autonomic dysfunction. Inconsistency in observation of such an effect in patients with diabetes in the past may well have been due to differences in the duration of diabetes

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

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

Cardiac manifestations in patients of rehumatoid arthritis

Abstracts: Cardiovascular manifestations of Rheumatoid arthritis have never been studied before therefore this study was designed to evaluate cardiac disease in patients suffering from rheumatoid arthritis

Methodology: Fifty patients of Rheumatoid Arthritis presenting in Out Patient, Emergency and Rheumatology Clinic of Mayo Hospital Lahore from March 1998 till January 1999 were studied. All of them full filled the criteria for the diagnosis of Rheumatoid Arthritis as described by the American Rheumatism Association. After history and physical examination, a clinical assessment of the patient was made of whether he / she had Cardiac Manifestations of Rheumatoid Arthritis or not

Results: Out of 50 patients seen 35 were female, and 15 were male. Giving a female to male ratio of 2.3 to 1. Maximum number of patients seen were between 26 45 years i.e 31[62%] In which 19 [38%] were between 26 to 35 years and 12 [24%] were between 36-45 years. Next most frequent group was of 8 [16%] patients, between 15-25 years of age. Short systolic murmurs were heard in four patients. One patient showed pulsus paradoxus while in the rest no rhythm irregularity was felt. Myocarditis or Coronary Rheumatoid disease was not noticed in any patient. No heart block of any degree was seen. In 4 E.C.G's low voltage was demonstrated in the limb leads. Out of 50 Patients only 3 had pericardial effusion. In one patient it was only a thin rim more prominent posteriorly than anteriorly

Conclusion: Cardiac manifestations of Rheumatoid Arthritis also occur in Pakistani Population, although not with the same frequency as in the Western world. It is also concluded that in Pakistani population, like in the West, the most common Cardiac complication is Pericardial Effusion

Assessment of diastolic function parameters with ECG gated myocardial perfusion spect: comparison of Two algorithms

Background: To compare Cedars-Sinai QGS and Michigan University Corridor4DM algorithms for determination peak filling rate [PFR], time to peak filling rate [TPFR] and mean filling rate in first third of diastole [MFR3] using 16 frames gated myocardial perfusion single photon emission computed tomography [SPECT]. To determine inter-observer reproducibility of Cedars QGS and Michigan University Corridor4DM for determination PFR, TPFR and MFR3 using 16 frames gated myocardial perfusion SPECT

Methods: Forty patients [28 males and 12 females] with age range 35-70 years [mean 58.85+/-8.82] referred for assessment of left ventricular perfusion and function were included in the study. All patients were injected 1100 Mega Becquerel [MBq] of freshly prepared [99m]Tc Sestamibi. One hour later, patients underwent gated myocardial perfusion SPECT on Siemens ecam dual head variable angle gamma camera using 16 frames per cardiac cycle. Data were reconstructed using filter back projection and re-orientated to generate short axis slices. Short axis slices were processed with QGS and Corridor 4DM for assessment of PFR, TPFR and MFR3 by two observers. Data from both observers were compared to determine inter-observer reproducibility of both methods. Observeri PFR, TPFR and MFR3 values derived from QGS and Corridor4DM were compared and correlated

Results: Peak filling rate values determined with Cedars QGS program were not significantly different from those determined with Corridor4DM [p= 0.564]. Good correlation was found between QGS and 4DM measured PFR values [R[2]=0.6698]. TPFR values determined with QGS program were not significantly different from those determined with Corridor 4DM program [p= 0.615]. However, there was poor correlation between these two methods with R[2] value =0.0382. MFR3 values determined with QGS were not statistically different from those derived from 4DM [p=0.587]. However, there was poor correlation between these values R[2]= 0.0174. Cedars QGS algorithm was highly reproducible for determination of PFR, TPFR and MFR/3 with R2 values of 0.9922, 0.9874 and 0.9932 respectively. PFR, TPFR and MFR3 derived from Corridor4DM were also highly reproducible with R[2] values of 0.7775,0.8381 and 0.456 respectively

Conclusions: Both Cedars QGS and Michigan University Corridor 4DM programs are robust for determination of PFR, TPFR and MFR3 diastolic function parameters. There is good correlation between QGS and 4DM derived PFR measurements. However, there is poor correlation between QGS and 4DM derived TPFR and MFR3 values

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

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

Predictors of positive thallium 201 single photon emission computed tomography in patients of end stage renal disease

To study coronary artery disease [CAD] risk factors predicting positive thallium-201 single photon emission computed tomography [SPECT] indicating underlying CAD among patients of end stage renal disease. This cross-sectional [analytical] study was done at Department of Cardiology, Punjab Institute of Cardiology, from April 2004 to Dec 2007. One hundred consecutive patients with ESRD undergoing thallium SPECT as a routine screening test before renal transplant were studied. Dipyridamole thallium SPECT was performed in patients who were unable to exercise. Thallium SPECT was positive in 47 [47%] cases. There were significant differences in age, underlying diabetic nephropathy and total cholesterol levels among patients positive and negative on thallium SPECT. Among the risk factors age and underlying diabetic nephropathy were significantly associated [p<0.05] with a positive thallium SPECT in patients with ESRD. Positive thallium SPECT indicating underlying CAD was observed in a significant number of patients with ESRD awaiting renal transplant. Presence of advanced age and underlying diabetic nephropathy predict a positive thallium SPECT in this population

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

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

Mid-term results of endarterectomy in advanced coronary artery disease

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

Three pregnancies with mechanical heart valve and no follow-up in 10 years

Anticoagulation and proper INR [International Normalized Ratio] monitoring is essential for patients having mechanical heart valves; it is vital in these patients in order to prevent lethal complications such as valve thrombosis and systemic embolism. In pregnancy, it becomes even more important as pregnancy itself is a hypercoagulable state. This report describes a female patient having undergone mitral valve replacement with a Starr Edward metallic prosthesis. She came back to the operating surgeon after 10 years of valve replacement with a history of three uneventful healthy deliveries and no follow-up and INR monitoring during this period

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

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

Exercise tolerance test: a comparison between true positive and false positive test results

To study the factors which predetermine the coronary artery disease in patients having positive Exercise Tolerance Test [ETT] after comparing the ETT test results and coronary angiographic findings in true positive and false positive groups. This Cross-sectional study was conducted at Punjab Institute of Cardiology, Lahore from January 1, 2004 to December 31, 2004. All patients who had ETT done for chest pain diagnosis were studied. Patients were advised coronary angiography if ETT was positive for exercise induced ischaemia. One hundred and forty eight patients had coronary angiography done after positive ETT. Patients were divided into two groups depending upon the angiographic findings, i.e., true positive and false positive. Both groups were compared with each other. Results: Out of 148 patients, 126 [85.1%] patients had true positive ETT and 22 [14.9%] patients had false positive ETT. The mean age of patients in true positive group was 48.96 +/- 9.08 years and 50.9 +/- 7.85 years in false positive group. One hundred and eighteen [93.7%] male patients and 8 [6.3%] female patients had true positive ETT, whereas 14 [63.6%] males and 8 [36.4%] females had false positive ETT [p < 0.0001]. There was no statistically significant difference in the two groups in comparison of age and other conventional risk factors like diabetes mellitus, hypertension, smoking, family history and dyslipidemia. Abnormal resting ECG had a statistically significant difference between the groups [p < 0.04], likewise is hypertensive haemodynamic response during ETT [p < 0.003]. The symptom limited ETT as compared to no symptoms during ETT also conferred a statistically significant difference between the groups [p<0.0001]. Strongly positive ETT was also associated with true positive ETT [p < 0.002]. Amongst the vessels involved the most common was the LAD 113 [89.7%], followed by LCX 80 [63.5%] and the RCA 72 [57.1%]. Most of the patients 51 [40.5%] had three vessel disease as compared to SVD 34 [27%]. It can be concluded that amongst the patients who have positive ETT, females with abnormal resting ECG, who achieve target heart rate and have a hypertensive haemodynamic response with no symptoms are likely to have a false positive test result. Conversely male patients with normal resting ECG who do not achieve target heart rate, have a normotensive haemodynamic response and a strongly positive, symptom limited ETT are likely to have a true positive treadmill test result

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

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

Role of exercise stress testing in evaluation of patients presenting with chest pain

To evaluate and assess the accuracy of the clinical diagnosis of ischemic heart disease [IHD] with exercise stress testing in patients presenting with chest pain. All patients referred from outdoor and emergency department were sent to exercise tolerance test [ETT] room, after undergoing full clinical assessment including history, examination and resting ECG. The patients underwent exercise testing according to Bruce Protocol. One hundred and twenty patients underwent exercise stress testing between December 2002 and June 2003. Among these 86 [71.7%] were males and 34 [28.3%] were females. The mean age of males was 45.19+9.49 years and females 44+10.9 years. Out of 120 patients, 50[41.6%] and 70 [58.3%] patients had positive and negative stress testing results respectively. Out of 50 positive cases, 33 [66%] were males and 17 [44%] were females. The mean age of patients with positive test was 51.3+8.3 years and negative test was 40.4+8.5 years. Hypertension was the most prevalent risk factor 42[35%] followed by family history 36[30%]. Out of total diabetics [18/120] twelve [66%] had positive test. A significant number of patients [n=30/38, [79%] with no risk factors were negative on stress testing. This study concludes that exercise stress test is a cost effective tool to evaluate patients presenting with chest pain in out-patients department suggestive of ischemic heart disease, both typical / definite angina as well as atypical / probable angina. This also helps to stratify those with increased likelihood of IHD into high-risk group needing referral for invasive tests and low risk group that can be observed