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

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

Relationship between BMI and severity of coronary artery disease in female population of Pakistani origin

Objective: To assess relationship between BMI and severity of coronary artery disease in female population of Pakistani origin

Design: Cross sectional observational study

Place and Duration of Study: Armed Forces Institute of Cardiology-National Institute of Heart Diseases [AFIC-NIHD], 1st February 2010 to 31st August 2010 Patients and Methods: The study population included 132 female patients undergoing coronary angiography. Obesity was classified according to the BMI using the National Institutes of Health [NIH] criteria as Normal [BMI 21-24 kg/m2], overweight [BMI 25-29 kg/m2], obesity class I [BMI 30-34 kg/m2], Obesity class II [BMI 35 to 39 kg/m2 and obesity class III [BMI 40 or above kg/m2]. Coronary angiography data were obtained from the Siemens Queries software system, which maintains the database including detailed angiographic findings of all patients at this institution. Significant lesions were defined as those with>70% diameter narrowing of coronary arteries [>50% for the left main coronary artery]. We attempted to quantify the "severity of CAD" by ascertaining the prevalence of high-risk coronary anatomy [HRCA, defined as>50% stenosis of the left main coronary artery and/or significant three-vessel coronary artery disease]

Results: Comparing overall obese [BMI >/= 30] vs. non obese groups, a statistically significant low prevalence of HRCA was encountered in the obese group [26 of 56, 46.4% vs. 54 of 76, 79.5% p<0.05] We concluded that obesity is associated with less severe coronary artery disease in women population of Pakistani origin

Relationship between BMI and severity of coronary artery disease in female population of Pakistani origin

To assess relationship between BMI and severity of coronary artery disease in female population of Pakistani origin. Cross sectional observational study. Armed Forces Institute of Cardiology - National Institute of Heart Diseases [AFIC-NIHD], 1st February 2010 to 31st August 2010. The study population included 132 female patients undergoing coronary angiography. Obesity was classified according to the BMI using the National Institutes of Health [NIH] criteria as Normal [BMI 21-24 kg/m2], overweight [BMI 25-29 kg/m2], obesity class I [BMI 30-34 kg/m2], Obesity class II [BMI 35 to 39 kg/m2 and obesity class III [BMI 40 or above kg/m2]. Coronary angiography data were obtained from the Siemens Queries software system, which maintains the database including detailed angiographic findings of all patients at this institution. Significant lesions were defined as those with >70% diameter narrowing of coronary arteries [>50% for the left main coronary artery]. We attempted to quantify the "severity of CAD" by ascertaining the prevalence of high-risk coronary anatomy [HRCA, defined as >50% stenosis of the left main coronary artery and/or significant three-vessel coronary artery disease]. Comparing overall obese [BMI >/= 30] vs. non obese groups, a statistically significant low prevalence of HRCA was encountered in the obese group [26 of 56, 46.4% vs. 54 of 76, 79.5% p < 0.05]. We concluded that obesity is associated with less severe coronary artery disease in women population of Pakistani origin

Left radial artery approach for coronary artery intervention

To determine the success rate of left radial artery approach for coronary intervention. Descriptive study. Armed Forces Institute of Cardiology/ National Institute of Heart Diseases Rawalpindi. Study Period spanned from 15 January 2010 to 15 July 2010. The study was conducted on a total of 41 patients, out of these 41 patients, 25[61%] had undergone diagnostic coronary angiography using left radial artery approach and 16[39%] underwent percutaneus coronary intervention. Left radial artery route was selected after Positive Allen Test. Injection Verapamil 5mg was given through side connection of radial artery sheath to prevent spasm. No conversion to femoral artery route was done, establishing 100% success rate, without any bleeding or haematoma. Left radial artery approach for coronary angiography and percutaneus intervention in convenient and safe for the patient and almost free from major access site complication

Dual source multislice computed tomography for pulmonary embolism: initial experience at AFIC/NIHD Rawalpindi

Observation of different computed tomography findings in patients suffering from pulmonary embolism. All patients who underwent computed tomography for pulmonary embolism and had positive findings of pulmonary embolism, were included in the study. Armed Forces Institute of Cardiology/ National Institute of Heart Disease, between April 2009 and October 2010. Patients on mechanical ventilation were excluded from the study. CT pulmonary angiograms were obtained with 64 slice dual source computed tomography [DSCT] machine [Somatom definition] from Siemens. Before scanning breath holding was taught. A craniocaudal acquisition was obtained with a collimation of 64 x 0.6 mm and a pitch of 1.2-1.4. Total number of patients included in the study were 34 with mean age 50 years. The mean of Score by Miller was 10 +/- 5.532 and the mean percentage obstruction by method of Miller was 62.5%. The mean of Score by Qanadli was 19.62 +/- 12.32 and the mean percentage obstruction by method of Qanadli was 49.04%. The mean of Score by Mastora was 54.53 +/- 33.27 and the mean percentage obstruction by method of Mastora was 35.18%. Calculated mean and SD of right ventricular [RV] diameters was 44 +/- 7.75mm, left ventricular [LV] diameter was 32 +/- 8.06mm, RV/LV ratio was 1.508 +/- 0.58 mm, main pulmonary artery [PA] luminal diameter was 29 +/- 4.16mm, ascending aorta size was 32.46 +/- 5.14mm, PA/Aorta ratio was 0.913 +/- 0.188mm, Azygos Vein diameter was 11.14 +/- 1.88mm and superior vena cava [SVC] diameter [at azygos arch] was 18.93 +/- 3.37 mm. Correlation between methods was generally significant. Reflux of contrast injection was noted in 24 out of 34 patients, leftward bowing of inter-ventricular septum was observed in 21 patients, pleural effusion was noted in 10 patients and pericardial effusion was seen in only 3 patients. CT pulmonary angiography has emerged as a reliable non invasive tool for not only confirmation of diagnosis of pulmonary embolism in short time but also gives valuable information about prognosis of these critically ill patients. Further it can provide accurate follow up of thrombolytic therapy and can help plan an interventional strategy

Transulnar access for coronary angiography and intervention

To assess the safety and efficacy of a transulnar approach for coronary catheterization. Descriptive study. Armed Forces Institute of Cardiology - National Institute of Heart Diseases [AFIC-NIHD], October 2009 to January 2010. Twenty five patients underwent coronary catheterization by the transulnar approach. Patients were selected for ulnar approach coronary angiography if they had a weak radial pulse with a stronger palpable ulnar pulse with a positive reverse Allen's test [< 10 sec]. No attempt was made at cannulating radial artery in the same sitting. A 6F sheath was placed inside the ulnar artery as per standard Seldinger technique, and cardiac catheterization or angioplasty was performed. The patients were examined before discharge from the hospital for any access site complications. Mean age of the patients was 48 years [range 30 to 62 years] and 80% [n= 20] were men and 20% [n=5] were females. Successful puncture was achieved in 100% [25/25]. One out of twenty five patients had same sitting PCI with stenting to LAD and LCX. No case of arterial spasm, haematoma, pseudoaneurysm, vascular perforation or loss of pulse was observed. We conclude that the transulnar approach is a safe and efficacious alternative for diagnostic and therapeutic coronary intervention in presence of weakly palpable radial artery and a stronger palpable ulnar artery with positive reverse Allen's test

Transradial access for pci: a novel approach / changing trends of vascular access

Vascular complications associated with femoral artery access for interventional cardiological procedures may increase morbidity especially in patients receiving anticoagulants, aspirin, clopidogrel and platelet glycoprotein IIb/ IIIa receptor inhibitors. The use of radial arterial access reduces the incidence of access site bleeding complications. The purpose of the present study was to assess the feasibility, success, and safety of the transradial approach [TRA] for PCI. Single-centre, Prospective observational study. The study was carried out in Armed Forces Institute of Cardiology - National Institute of Heart Diseases [AFIC-NIHD] over a period of six months from july 2009 to december 2009. We collected data of 100 consecutive patients who underwent PCI by the transradial approach. Transradial access was performed only if the Allen's test was normal [positive], suggesting the presence of an adequate collateral circulation from the ulnar artery. Patients with previous CABG with LIMA grafting, ACS with cardiogenic shock or requiring TPM placement were excluded from this study. Study endpoints included procedure success rate, vascular complications at access site, and major adverse cardiac and cerebrovascular events during hospitalization. Mean age of the patients was 53 years [range 31-79 yrs]. Procedural success was achieved in 100% cases. Right TR approach was used in 99% cases. Number of target lesions treated was 239 with multivessel PCI done in 61% cases. DES was used in 72%cases and BMS was used in 28% cases. Maximum no of target lesions treated included LAD 114[47.6%], followed by RCA 50 [20.9%],LCX 41[17.1%],OM branch 25[10.4%],Diagonal branch 9[10.4%]. No case of vascular complications such as major access site bleeding, vascular perforation, radial artery occlusion, forearm ischemia or compartment syndrome was observed. There were no procedural myocardial infarctions or deaths, and no patient was referred for emergency bypass surgery. We conclude that the transradial access for PCI is a safe and effective alternative to transfemoral access. It adds to patients comfort and convenience and offers coronary intervention with the potential of less vascular complications

Transradial access for coronary angiography: a single operator's experience of 500 cases

The purpose of the present study was to assess the feasibility, success, and safety of the transradial approach [TRA] for diagnostic coronary angiography. Descriptive study. The study was carried out in Armed Forces Institute of Cardiology-National Institute of Heart Diseases [AFIC-NIHD] over a period of ten months from June 2009 to March 2010. We collected data of 500 consecutive patients who underwent coronary catheterization by the transradial approach. Transradial access was performed only if the Alien's test was normal [positive]. Patients with previous CABG or requiring right heart catherization were excluded from this study. Study endpoints included procedure success rate, vascular complications at access site, and major adverse cardiac and cerebrovascular events during hospitalization. Mean age of the patients was 52 years [range 33-77 yrs] and 72.8% [n= 364] were men and 27.2% [n=136] were females. The vast majority of cases [98.4%] were elective. The right radial artery was used in 98% of cases. Procedural success was achieved in 90.6% cases [453/500]. No case of vascular complications such as major access site bleeding, vascular perforation, radial artery occlusion, forearm ischemia, compartment syndrome or MACE was observed. Transradial access for coronary angiography is a safe, effective and elegant alternative to transfemoral access

N-butyl-2-cyanoacrylate and lipoidol pulmonary embolism [glue embolism]

Glue embolisation is a rare happening and many clinicians who evaluate patients for post sclerotherapy problems may be unaware of this complication. We present a case of pulmonary embolism in a patient of cirrhosis liver secondary to gastric variceal sclerotherapy with N-Butyl-2-cyanoacrylate and lipoidol solution. This is also called glue embolism

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

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

Design: prospective observational study

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

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

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

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