Clinical pathways for non-ST elevation acute coronary syndrome in Oman: an Oman heart association protocol for hospital quality improvement initiative

In 2012, Oman Heart Association [OHA] published its own guidelines for the management of patients with unstable angina/ non-ST-elevation myocardial infarction, the aim was not to be comprehensive but rather simplified and practical in order to reduce the gap between the long comprehensive guidelines and our actual practice. However, we still feel that the busy registrars and residents need simpler and direct clinical pathways or protocol to be used in the emergency departments, coronary care units and in the wards. Clinical pathways are now one of the main tools used to manage the quality in healthcare concerning the standardization of care processes. It has been shown that their implementation reduces the variability in clinical practice and improves outcomes in acute care

Procedural and clinical utility of transulnar approach for coronary procedures following failure of radial route: Single centre experience

Objectives: To assess the feasibility and safety of transulnar approach whenever transradial access fails

Background: Radial access for coronary procedures has gained sound recognition. However, the method is not always successful

Methods: Between January 2010 and June 2013, diagnostic with or without percutaneous coronary intervention [PCI] was attempted in 2804 patients via the radial approach. Transradial approach was unsuccessful in 173 patients [6.2%] requiring crossover to either femoral [128 patients, 4.6%] or ulnar approach [45 patients, 1.6%]

Patients who had undergone ulnar approach constituted our study population. Selective forearm angiography was performed after ulnar sheath placement

We documented procedural characteristics and major adverse cardio-cerebrovascular events

Results: Radial artery spasm was the most common cause of crossover to the ulnar approach [64.4%] followed by failure to puncture the radial artery [33.4%]

Out of 45 patients [82.2%], 37 underwent successful ulnar approach

The eight failed cases [17.8%] were mainly due to absent or weak ulnar pulse [75%]. PCI was performed in 17 cases [37.8%], of which 8 patients underwent emergency interventions

Complications included transient numbness, non-significant hematoma, ulnar artery perforation, and minor stroke in 15.5%, 13.3%, 2.2% and 2.2%, respectively

No major cardiac-cerebrovascular events or hand ischemia were noted

Conclusion: Ulnar approach for coronary diagnostic or intervention procedures is a feasible alternative whenever radial route fails. It circumvents crossover to the femoral approach

Our study confirms satisfactory success rate of ulnar access in the presence of adequate ulnar pulse intensity and within acceptable rates of complications

Comparative study of ambulatory blood pressure monitoring and clinic blood pressure measurement in the risk assessment and management of hypertension

Blood pressure [BP] measurements taken in a physician's clinic do not represent readings throughout the day. Ambulatory blood pressure monitoring [ABPM] overcomes this problem by providing multiple readings with minimal interference with the patient's daily activities. The purpose of our study was to evaluate the value of ABPM in risk assessment and management of hypertension compared to office measurements. A total of 104 consecutive hypertensive patients were retrospectively studied from January 2007 to December 2009. The following data were gathered: 1] clinic BP measurements; 2] routine blood test results; 3] electrocardiography, echocardiography, and 4] 24-hour ABPM. The mean age of patients was 41.1 +/- 8.6 years and 51.9% of them male. Indications for ABPM were: suspected "white coat" hypertension [10.6%], de novo hypertension [18.2%], resistant hypertension [27.9%] and others [43.3%]. Mean daytime and nighttime BP were 134/82 and 124/73 mmHg respectively. A non-dipping pattern was reported in 64.4%. Echocardiographic evidence of left ventricular hypertrophy [LVH] and diastolic dysfunction [LVDD] was encountered in 22.1% and 29.8% respectively. ABPM parameters were significantly correlated with LVDD [P = 0.043]. Patients with proved [white coat] hypertension did not receive antihypertensive therapy. Twenty-four hour ABPM is an important yet underused tool for proper risk stratification of treated hypertensive patients. The non-dipping profile is associated with a higher incidence of diastolic dysfunction. Our collective results revealed the superiority of ABPM over office BP measurement

Asymptomatic permanent left bundle branch block [LBBB] complicating diagnostic left heart catheterisation

This case report describes a routine diagnostic left heart catheterisation [coronary angiography, aortography and left ventriculography] procedure at Sultan Qaboos University Hospital, Oman, which was complicated by the development of new asymptomatic, but permanent, left bundle branch block that was observed incidentally towards the end of the procedure. The patient was completely asymptomatic and haemodynamically stable throughout the procedure and afterwards. Urgent investigations, immediately after the procedure, including routine blood, serial cardiac troponin I, serial electrocardiograms, chest X-ray, and urgent echocardiography were normal and failed to show any possible causation of the LBBB. The results of left heart catheterisation showed two vessel coronary artery disease and severe mitral valve regurgitation. After eight days, the patient went on to have coronary artery bypass surgery and mitral valve replacement surgery both of which were successful. To the best of our knowledge, this is the first case report to describe the occurrence of permanent LBBB after left heart catheterisation. This report describes the case and reviews the literature for the incidence and implications of such a complication

Diagnostic value of electrocardiographic T wave inversion in lead aVL in diagnosing coronary artery disease in patients with chronic stable angina

The clinical value of T wave inversion in lead aVL in diagnosing coronary artery disease [CAD] remains unclear. This study aims to investigate the correlation between aVL T wave inversion and CAD in patients with chronic stable angina. Electrocardiograms [ECGs] of 257 consecutive patients undergoing coronary angiography were analyzed. All patients had chronic stable angina. All patients with secondary T wave inversion had been excluded [66 patients]. The remaining 191 patients constituted the study population. Detailed ECG interpretation and coronary angiographic findings were conducted by experienced cardiologists. T wave inversion in aVL was identified in 89 ECGs [46.8%] with definite ischemic Q-ST-T changes in different leads in 97 ECGs [50.8%]. Stand alone aVL T wave inversion was found in 27 ECGs [14.1%] while ischemic changes in other leads with normal aVL were identified in 36 ECGs [18.8%]. The incidence of CAD was 86.3%. Single, two-and multi-vessel CAD were found in 38.8%, 28.5% and 32.7% of cases respectively. The prevalence of left main, left anterior descending, left circumflex and right coronary arteries were 4.7%, 61.2%, 29.3% and 44.5%, respectively. T wave inversion in aVL was found to be the only ECG variable significantly predicting mid segment left anterior descending artery [LAD] lesions [Odds Ratio 2.93, 95% Confidence Interval 1.59-5.37, p=0.001]. This study provides new information relating to T wave inversion in lead aVL to mid segment LAD lesions. Implication of this simple finding may help in bedside diagnosis of CAD typically mid LAD lesions. However, further studies are needed to corroborate this finding

Retrieval of dislodged central venous pressure catheters: early experience with three case presentations

Central venous catheters [CVP] are frequently used in clinical practice. Occasionally, catheters may become dislodged. If percutaneous retrieval fails, then cardiothoracic surgery is necessary to retrieve the fractured catheter and avoid potential complications. This report describes early experiences of three different modes of broken catheter retrieval: the first by use of a snare catheter; the second by surgery and the third during bypass surgery. We conclude that broken fragments of catheters that lodge in the right side of the heart or pulmonary circulation can be retrieved most of the time percutaneously by snare catheters

Comparative study of the radial and femoral artery approaches for diagnostic coronary angiography

Femoral artery access is the standard approach for coronary procedures; however, the radial approach has gained sound recognition as an alternative to femoral access. We present our early experience with the transradial approach. A prospective, non-randomised study of 221 candidates for diagnostic coronary angiography was carried out at Sultan Qaboos University Hospital, Oman between December 2008 and April 2009. The patients had their procedure performed from radial or femoral access according to operator discretion and the results were compared. Femoral and radial groups included 116 and 105 patients respectively. Results: Radial access was associated with a significantly higher rate of procedural failure [17.1%] versus 0% in femoral group [p=0.001]. There were no local vascular complications in the radial group as opposed to 12.1% in the femoral group [p < 0.01]. Hospital length of stay was significantly reduced in the radial group [4.06 versus 23.5 hours, p < 0.01]. Total procedure time was longer in the radial group [23.7 +/- 13.7 min versus 20.1 +/- 7.4 min, p < 0.001], but radiation exposure was similar in both groups. There was a trend for a higher risk of major adverse cardiac events noticed in the femoral group; however, it did not reach statistical significance. The transradial approach for coronary angiography is associated with significantly reduced local vascular complications and shorter hospital stays. The femoral approach is the standard access site for coronary angiography; however, interventional cardiologists should acquire experience in the radial approach as an alternative in specific situations

Efficacy and safety of direct coronary stenting: acute outcome of direct stenting in type A, B, and C lesions

Direct stent implantation is the unique technique of an intracoronary stenting without lesion predilation. It acquired sound acceptance and popularity due to shorter procedural time, fewer contrast dose and reduced incidence of clinically relevant dissections, furthermore, cost effectiveness and less radiation exposure favor this approach. However, the abuse of this technique may result in worse outcome. The objective beyond this study was to assess the safety and feasibility of the direct stenting in different lesion subsets [Type A, B and C]. A prospective non randomized study of 78 patients with total of 84 lesions [29 type A, 41 type B, and 14 type C] underwent direct stenting., Lesions were classified accordingto AHA/ACC task force. TIMI flow before and after procedure, dissectons, perforation, residual diameter stenosis and side branch compromization all were considered. Initial deployment was successful in 80 out of 84 lesions, three lesions successfully stented following predilation. A stent was unable to be deployed in only lesion; however, the lesion was treated with balloon angioplasty alone, all were complex type C lesions and excluded from study. The majority of lesions required only 1 stent [an average of 1.03 stents was used per lesion]. Compared with pre-procedural TIMI flow, post procedure TIMI flow has improved in all lesion subsets, however, it didn't reach a statistical significance except in type B lesions [p=0.007], residual diameter stenosis was significantly higher in type C compared to Type B and A lesions [32.0, 11.62 and 1.67% respectively, p=0.001], side branch compromization observed in 60%, 35.9% and 17.2% in type C, B and A lesions respectively [0.0 15]. Distal dissection observed in 60%, 2.4% and 0% in type C, B and A lesions respectively [p=0.002]. Vessel perforation has complicated primary stenting of type C lesion that successfully treated by prolonged inflation and deployment of another stent, resulting in procedural myocardial infarction. Direct stenting is a safe and effective method for treating coronary artery disease except for complex type C lesions in which complications are warranted

Utility of plasma n-terminal pro brain natriuretic peptide in the assessment of left ventricular systolic dysfunction

The diagnosis of heart failure [HF] is difficult, with both overdiagnosis and underdiagnosis occurring commonly in practice. Echocardiography is a standard technique in the evaluation of left ventricular function. Natriuretic peptides have been proposed as useful markers of left ventricular dysfunction. The aim of the study was to evaluate the utility of plasma amino-terminal pro-brain natriuretic peptide [NT-proBNP] for the detection of left ventricular systolic dysfunction. We measured NT-proBNP in 70 patients referred for cardiac and echocardiographic evaluation due to known symptomatic HF in 20 and high risk for HF in 50 patients. Left ventricular ejection fraction [LVEF] was determined by echocardiography and patients were categorized into 2 groups, patients with LVEF >45% and patients with LVEF<45%. There were 39 patients with LVEF >45% [31 men and 8 women with a mean age of 53 +/- 5.1 years] and 31 patients with LVEF <45% [29 men and 2 women with a mean age of 59 +/- 6.1]. There were no differences between groups regarding age or body mass index. The mean NT-proBNP concentration in patients with LVEF <45% was significantly higher than that in patients with LVEF >45% [1025 +/- 697.5 pg/ml vs. 55 +/- 30.3 pg/ml, p<0.0001]. All patients with LVEF <45% had NT-proBNP value >100 pg/ml and 36 of 39 patients with LVEF >45% had NT-proBNP value <100 pg/ml. Using this cut-off value the NT proBNP was 100% sensitive and 92% specific with negative predictive value of 92% and positive predictive value of 94% for detection of patients with LVEF <45%. Our results suggest that measurement of NT-proBNP with a commercially available diagnostic kit can be reliable for detection of left ventricular systolic dysfunction as indicated by LVEF <45%

Left ventricular structural alterations in treated hypertensives with or without nocturnal fall in blood pressure

The lack of the normal nocturnal fall in blood pressure in hypertensive patients has been suggested to augment target organ damage. The aim of our study was to assess the effects of dipper and non-dipper BP profiles, in treated hypertensives on left ventricular structural alterations. This study included 85 patients with treated hypertension. They were divided into 2 groups, group I included 26 patients with controlled clinic BP and group II, included 59 patients with ucontrolled and resistant BP. All patients underwent 24-hour ambulatory blood pressure [BP] monitoring and echocardiographic examination. Using ambulatory BP measurements patients were classified into dipper and non-dippers in each group. Using echocardiographic measurements of left ventricular [LV] dimensions, LV mass was calculated and indexed for body surface area to obtain the left ventricular mass index [LVMI]. LV hypertrophy [LVH] was diagnosed when LVMI was >110g/m2 in women and >134g/m2 in men. LV relative wall thickness [LVRWT] was calculated with values <0.45 were considered normal for both sexes. LV geometric pattern was estimated according to the relation between LVMI and relative wall thickness. The prevalence of non-dippers was significantly higher in group II [53%] than in group I [31%]. There were no differences in the demographic and metabolic characteristics as well as mean 24-h BP values in dippers and non-dippers in both groups. There was higher prevalence of LVH in group II [37%] compared to group I [19%]. However, the prevalence of LVH was similar in dippers and non-dippers in group I [16% and 25%, respectively] and group II [61% and 65%, respectively]. LVM, LVMI, LVRWT and LV fractional shortening were similar in dippers and non-dippers in both groups. Most patients in group I had normal LV geometry with only 2 patients of each of the dippers and non-dippers showing eccentric LVH. Group II patients had higher incidence of concentric LVH both in dippers and non-dippers [39% and 42 and respectively]. Our results indicate that the non-dipping BP profile, diagnosed on the basis of a single ABPM, in treated hypertensives with or without BP control is not associated with an increase prevalence of LVH or LV geometric alterations

Instent restenosis predictors of long coronary lesions

Balloon angioplasty of long coronary stenoses has been reported to be associated with a lower rate of acute clinical and procedural success and a higher rate of restenosis compared to short lesions. Intracoronary stenting has been shown to reduce restenosis, however, instent restenosis remains a major clinical problem despite improved stent flexibility and wall coverage and operator experience. The purpose of this study was to identify clinical, angiographic, and procedural predictors of restenosis after coronary stent placement in lesions longer than 15 millimeter. We analyzed the 6 month angiographic outcome of 378 patients [420 lesions]. All patients with successful coronary stent deployment and 6 month follow up were eligible for this study. Quantitative coronary coronary angiography [QCA] and intravascular ultrasound [IVUS] analyses were obtained immediately after stent deployment, and QCA at 6 months follow up. Restenosis was observed in 33.3% of lesions. By univariate analysis, stent length, number of stents per patient and per lesion, final IVUS lumen cross sectional area [CSA], and patients with multivessel disease were identified as the potential predictors of restenosis. Multivariate analysis identified final lumen CSA [OR= 0.85;95% CI=0.74-0.98, p=0.031] and stent length [OR=1.04;95% CI= 1.02-106, p=0.0001] as the only independent predictors of restenosis. Coronary stenting is associated with acceptable restenosis rate in this highly vulnerable cohort of lesions. Achieving an optimal final stent lumen CSA, and minimizing stent length as possible may help to reduce incidence of restenosis in this high risk group of lesions

value of right ventricular outflow-tract fractional shortening for assessment of right ventricular function

Assessment of right ventricular function is important. However, this is not easy to achieve due to the complex anatomy and geometry of the right ventricle, making the evaluation of its function limited. Therefore, a simple reliable and easy method is needed. This work was to evaluate the use of right ventricular outflow tract fractional shortening obtained by M-mode echocardiography as a measure of right ventricular systolic function in patients having inferior wall myocardial infarction with or without evidence of right ventricular infarction [as a model of right ventricular disease]. Fifty patients with first acute inferior wall myocardial infarction, their ages ranged from 30 to 80 years with [mean +/- SD = 54.56 +/- 11.5], were investigated. Ten healthy controls also were studied. M-mode echocardiography was used to measure right ventricular outflow tract fractional shortening and right ventricular long axis excursion. Two-dimension echocardiography was used to measure right ventricular ejection fraction. Ventricular outflow tract fractional shortening [p<0.0001], right ventricular long axis excursion [p<0.0001] and right ventricular ejection fraction [p<0.0001] were reduced in patients compared to controls. Also were reduced in patients in group [B] compared to patients in group [A]. Right ventricular outflow tract fractional shortening correlated with long axis excursion [r=0.86, p<0.0001], right ventricular ejection fraction [r=-0.84, p<0.0001]. Right ventricular outflow tract fractional shortening provides a simple and non-invasive measure of right ventricular systolic function and could be helpful in diagnosis of right ventricular infarction in patients have inferior wall MI. In combination with long axis excursion and Doppler velocities, they should provide comprehensive assessment of right ventricular function

Twenty four-hour ambulatory blood pressure monitoring in detection and management of hypertension compared to clinic readings

Blood pressure measurements taken in a physicianis clinic or by patients themselves don't represent readings throughout the day. Ambulatory blood pressure monitoring [ABPM] overcomes this problem by providing multiple readings over time with minimal intrusion into the patient's daily activities. The purpose of our study was to evaluate the value of 24-hour ABPM in detection and management of hypertension over traditional over traditional office measurements. A total of 100 never-treated or already known essential hypertensive patients divided into 2 groups, first group included 50 patients managed according to 24 hour ambulatory blood pressure monitoring results and the second group 50 patients according to office blood pressure measurements. All patients underwent the following procedures: [i] repeated clinic blood pressure measurements, [ii] blood sampling for routine chemistry examinations; [iii] 24-hour urine collection for microalbuminuria; [iv]echocardiography; and ABPM for the first group. Main indications for ABPM were borderline hypertension [44%], de novo hypertension 20%] and resistant hypertension [36%]. Mean age of the first group was 44.1 +/- 9.8 versus 54.4 +/- 11.6 years [p=0.002] and 24-hour ambulatory blood pressure was 129/80 mmHg with mean +/- SD 11.4/10.1. ambulatory blood pressure monitoring has changed our treatment strategy in 80% of patients. Its parameters were significantly correlated with left ventricular hypertrophy [p=0.04], diastolic dysfunction [p=0.012], hypertension duration and body mass index than traditional clinic measurements did. Twenty four hours ambulatory blood pressure monitoring is an important yet underused tool for the management of hypertension patients especially those with borderline, recent onset and even resistant hypertension. Our collective results revealed superiority over office blood pressure measurement