Trends of utilizing medication, recommended by evidence based guidelines, for myocardial infarction, in a tertiary care hospital, "too far but not too dark"

Background: acute myocardial infarction [MI] is a major health problem with a substantial mortality and morbidity. Numerous guidelines have been established that should be followed in the management of acute MI

Objective: to determine whether the current practice in managing patients admitted with acute MI in a tertiary care hospital is evidence based compliant

Patients and Methods: this retrospective study was based on the record of the patients with diagnosis ofMI admittedbetween January to June 2007, at Sheikh Zayed Hospital, Rahim Yar Khan, who fulfilled the predefined criteria

Results: Total number of cases were 58, mean age of the study subjects was 47+ 8.65 years, with age range of 16 to 95 years. It was observed that 81% of study subjects were male. Half of the patients belonged to lower income group; Laborer and house wives were 3 1 % and 19% respectively. Sixteen percent of patients were hypertensive and diabetic. 19 % were smoker and 5% had family history of coronary artery disease. Anterior and inferior wall MI were reported in 64% and 32% of the patients, respectively. Injection Streptokinase [SK] was given to 52% of the patients. Aspirin, clopidogril and nitrates were given to all patients, whereas 34 % and 36% were prescribed Beta blocker [BB] and statins, respectively. Angiotensin converting enzyme inhibitor [ACEI] was given in 43% patients

Conclusion: SK, the only means of acute revascularization was given in only 52% patients mainly due to delayed presentation. Use ofAspirin is an unbeatable target and given to all patients. Use of BB and statins in < 40% and ACEI in<50% is not optimal. However, these trends of cardiac medication in a tertiary care hospital with limited provision, reflects the diffusion of light of evidence based medicine into darkness of periphery

Basic life support skills: assessment and education of spouse and first degree relatives of patients with coronary disease

To assess the knowledge of basic cardiac life support [BCLS] before and after the institution of training among first degree relatives and spouses of patients with coronary disease. Quasi-experimental study. National Institute of Cardiovascular Diseases, Karachi, from April 2007 to May 2008. A total of 300 relatives of patients with coronary heart disease undertook a one day CPR course. Questionnaire assessing knowledge of CPR was administered before and after the course. Patients were studied in groups of 10-20 at a time. Proportion of correct knowledge was compared using chi-square test with significance at p < 0.05. Mean age of participants was 31.08 +/- 10.53 years. Two hundred and twenty [73.34%] were males. On the average of all 31 questions, 37.09% of participants had correct responses before the training and 68.16% after the training of BCLS [p < 0.001]. There was statistically significant improvement across all age groups, gender and educational levels [p < 0.01]. There was significant improvement in relatives' knowledge of BCLS after training. Different age groups, both genders and all educational groups shoed equal learning abilities

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

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

Greek technique for type 4A coronary artery bifurcation lesions

In routine coronary angiography, bifurcation lesion is not uncommon. Current practice of dealing with type 4a coronary bifurcation lesions [lesions of main branch without significant lesions of the side branch] may lead to true bifurcation lesions after stenting due to axial plaque redistribution. This series describes an experience with Greek technique for treatment of type 4a bifurcation lesions in 18 patients for primary stenting of main vessel with simultaneous kissing balloon of side branch in an effort to avoid snow plough effect

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

Role of intravascular ultrasound [IVUS] in evaluating optimal inflation and size of stents and balloon in patients undergoing percutaneous coronary interventions [PCI]

Objective: To evaluate the size of balloon and stent and inflations given to patients undergoing PCI before and after IVUS. Design: A retrospective study. Place and duration of study: This retrospective study was conducted at department of catheterization laboratory National Institute of Cardiovascular Diseases [NICVD] Karachi from 1998 to 2001

Subjects and Methods: All patients who have undergone PCI in catheterization laboratory NICVD from 1998 to 2001 were included. These patients include those who have undergone IVUS in between year 2000 and 2001

Results: IVUS study and use of stents and balloon in four years showed that mean diameter of stent in males used increased from 3.05 mm to 3.13 mm and mean length reduced from 18.32 mm to 15.22 mm with inflations ranged from 9.30 atm to 13.4 atm. For Balloons mean diameter decreased from 2.7 mm to 2.6 mm and mean length reduced from 20.9 mm to 19.24 mm with inflations that increased from 5.04 atm to 6.4 atm. In females stent used with mean diameter that increased from 2.96 mm to 3.08 mm and mean mean length decreased from 18.33 mm to 15.47 mm and inflation increased from 9.33 atm to 12.69 atm. Balloon used with mean diameter that decreased from 2.9 mm to 2.6 mm with length that decreased from 20.8 mm to 19.04 mm and with inflations 6.20 atm to 5.80 atm

Conclusion: This study showed that IVUS demonstrated a significant increase in stent expansion after IVUS. Mean length of stent and balloon used decreased yearly. Mean diameter of stent used were increased while that of balloon decreased after IVUS

Transradial diagnostic and percutaneous coronary intervention

To describe the technique and rationale of coronary diagnostic and intervention procedures via radial artery. Design: A descriptive study. Place and Duration of Study: From January, 2000 to August, 2001 at National Institute of Cardiovascular Diseases [NICVD], Karachi. Subjects and A total of 167 [3.6%] patients underwent TR approach for both diagnostic and intervention procedures. The minimum age of the patients was 20 years whereas maximum age was 75 years. All patients with positive Allen's Test were included in the study. All the procedures were done by using the right radial artery approach. Out of 167 cases 76% were diagnostic and 24% were in Percutaneous Coronary Intervention [PCI] group. In 3% the radial artery approach was not successful. In PCI group disease, pattern was single vessel [58%] with mostly left anterior descending artery[LAD] involvement [44%]. Lesions were mostly low to moderate risk. In PCI group 51 stents both pre-mounted and un-mounted [bare] were used. In 19% cases, direct stenting was done while 12.5% patients received Abciximab and 7.5% patients underwent IVUS for lesion quantification. In PCI group, procedure was unsuccesful in 2.4% cases due to inability to cannulate and negotiate the lesion. In our limited local experience of 167 cases of TR approach, there were no major complications like major bleed, limb ischemia etc. The TR approach for invasive procedures yields comparable results to femoral approach. It has a major benefit of reduction in puncture site related complications vis-a-vis intensive use of anticoagulants, antiplatelet, and fibrinolytics required for PCI. Additionally, the approach also increases patient comfort through early mobilization and reduction in cost