Validity of electrocardiographic QT Interval in predicting left ventricular diastolic dysfunction in patients with suspected heart failure

Objective: To determine the validity of electrocardiographic QT interval in predicting left ventricular diastolic dysfunction in patients with suspected heart failure using echocardiogram as the gold standard

Study Design: Cross-sectional validation study

Place and Duration of Study: AFIC-NIHD, Rawalpindi, from December 2012 to June 2013

Methodology: Patients with suspected heart failure undergoing 12-lead electrocardiogram and echocardiography were inducted. All electrocardiograms were analyzed by a single trained reader unaware of the echocardiographic findings. QTc interval was calculated according to the published guidelines. All patients underwent a complete M mode, 2 dimensional, Doppler, and tissue Doppler echocardiography using aiE33 ultrasound system and diastolic dysfunction was calculated

Results: Three hundred patients were studied. Descriptive statistics of age was 61.42 years +/- 10.43. Of all the patients 218 patients [72.7%] were male and 82 patients were female [27.3%]. Mean QT interval [msec] was 427.29 +/- 54.69. One hundred and eighty patients [60.0%] had diastolic dysfunction and 120 patients [40%] had no diastolic dysfunction. The sensitivity of electrocardiographic QTc interval in predicting diastolic dysfunction was 71.11% and specificity was 88.11%

Conclusion: Prolonged electrocardiographic QTc interval in patients with suspected heart failure is a useful tool in predicting diastolic dysfunction

Frequency of different disorders requiring warfarin therapy and its outcome in terms of dosage and INR value in Pakistani population

To determine the frequency of different disorders requiring warfarin therapy and to see the target INR and warfarin dose requirement in Pakistani population. Descriptive study. The study was carried out at Armed Forces Institute of Cardiology [AFIC] Rawalpindi, Military Hospital Rawalpindi and National Institute of Cardiovascular Diseases [NICVD], Karachi, Pakistan from October 2010 to March 2012. Stable patients taking warfarin therapy were recruited after detailed medical history, physical examination and laboratory tests. The demographic and clinical data of individuals were entered in a pre-structured proforma. Patients suffering from hepatic and renal disease, any co-morbid disease or taking any concurrent medication or diet which would have affected warfarin therapy, were excluded. Data was analyzed using SPSS version 20.0. A total of 607 stable patients fulfilling the eligibility criteria, participated in the study. There were 297 [48.9%] male and 310 [51.1%] female patients. The mean age was 37.93 +/- 12.23 years [range 18-65 years]. The most common indication for warfarin therapy was valvular heart diseases [93.4%] followed by atrial fibrillation [2.3%] whereas other indications for warfarin use are less commonly seen in our study population. Patients had mean international normalized ratio [INR] value of 2.3 +/- 0.8 [range 1.5-3.5]. Mean daily dose of warfarin calculated in 607 patients was 5.62 +/- 1.98 mg with the range of 0.36-15 mg whereas mean weekly dose was 39.36 +/- 13.8 mg with the range of 2.5-105 mg. In Pakistani population the most common indications for warfarin use are valvular heart diseases followed by atrial fibrillation. The mean INR values were within recommended range of 2-3. The mean daily dose observed in long-term therapy is comparable to the empirical dose of 5 mg routinely started in clinical practice

Correlation of global registry of acute coronary events [GRACE] with the angiographic severity and extent of coronary artery disease in patients with non- ST elevation acute coronary syndrome

To determine whether the GRACE risk score correlates with the angiographic extent and severity of coronary artery disease in patients with NSTE-ACS undergoing cardiac catheterization. We conducted a cross sectional descriptive study in 154 patients with NSTE-ACS admitted at AFIC-NIHD from 1[st] April to 30[th] September 2011. For each patient the GRACE risk score was calculated by using specific variables collected at admission. The extent and severity of coronary artery disease was evaluated on angiography for each patient. A total of 154 patients were included in the study. The average age of the patients was 55.81years. Majority [75%] of the patients was male and 25% were females. The mean GRACE score was 132.85. Overall 40 patients had low, 54 had intermediate, and 60 had high GRACE risk score. Among patients with low score 28 had SVCAD, 4 patients had DVCAD and none of the patients had TVCAD. In the intermediate group 24 patients had SVCAD, 18 had DVCAD and 6 had TVCAD whereas among the high GRACE risk score 4 patients had SVCAD, 24 had DVCAD and 32 had TVCAD. Regarding the severity of coronary artery disease; among the low GRACE risk score patients; 8 had subcritical and 32 had critical CAD. In the intermediate GRACE risk score subset of patients, 6 had subcritical and 48 had critical CAD and none of the patients of high GRACE risk score had subcritical CAD and all 60 patients had critical CAD. GRACE risk score is a valuable noninvasive tool in predicting the extent and severity of CAD

Culprit artery characteristics and severity of angiographic thrombus burden in primary percutaneous coronary intervention in patients presenting with ST elevation myocardial infarction

The purpose of study was to characterize culprit artery characteristics in terms of presence of thrombus burden in patients with acute myocardial infarction using prevalent parameters of thrombus estimation. Descriptive study. Adult cardiology departments of Armed Forces Institute of Cardiology / National Institute of Heart Diseases [AFIC/NIHD] from 1[st] October 2011 to 31[st] September 2012. We studied 119 patients treated with primary percutaneous coronary intervention for ST- segment myocardial infarction. Bare metal stents were used in all patients as per hospital protocol. Thrombus burden [TB] was graded [G] as GO = no thrombus, G1= possible thrombus, G2 = small [greatest dimension <, 1/2 vessel diameter [VD]], G3 = moderate [>1/2 but <2 VD], G4 large [>2 VD], G5 = unable to assess TB due to vessel occlusion. Patients with G5 were reassessed after passage of guide wire or small balloon for thrombus burden. Frequency of major adverse cardiac events [MACE]-defined as death, myocardial infarction and infarct- related artery revascularization was recorded for the pen-procedural period which was defined in our study up to 72 hours. Overall, in hospital MACE was 8.4%. Large thrombus burden is a significant predictor for mortality and MACE

Frequency and angiographic characteristics of coronary artery ectasia in patients undergoing coronary angiograms at AFIC and NIHD

To determine the frequency and angiographic characteristics of coronary artery ectasia in the patient population of AFIC and NIHD. Descriptive Study Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi from Jan 2007 to Dec 2011. All coronary angiograms done during the period were included in the study. The reports of coronary angiograms of those patients who were diagnosed to have coronary artery ectasia were left circumflex artery reviewed to assess the distribution of ectasia in different coronary arteries. Concomitant significant coronary artery stenosis left ventricular [LV] systolic function and history of revascularization were also documented. Over the study period, a total of 41,459 patients underwent coronary angiograms. 548 [1.32%] patients were diagnosed to have coronary artery ectasia. Out of these 467 [85.21%] patients were males and 81 [14.78%] were females. Their mean age was 53.7 years. Left anterior descending [LAD] was the coronary artery, most commonly affected by ectasia followed by left circumflex artery [LCx] and Right coronary artery [RCA]. Twenty three patients also had ectasia of left main stem. Four Hundred and three [73.54%] patients also had concomitant occlusive coronary artery disease and 19.52% patients had history of coronary revascularization either by percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]. Coronary artery ectasia is not a benign disorder as it could present as acute coronary syndrome having its own morbidity and mortality

Frequency of common modifiable risk factors in patients with myocardial damage undergoing single vessel coronary angioplasty

To determine the frequency of common modifiable risk factors in patients with myocardial damage undergoing single vessel coronary angioplasty. Descriptive study. Armed forces Institute of Cardiology / National institute of Heart Disease Rawalpindi from June 2012 to Nov 2013. Hundred patients undergoing elective single vessel percutaneous coronary angioplasty were evaluated with creatinine kinase and creatinine kinase MB levels before, after 8 hours and 24 hours following coronary angioplasty. The detailed performa was filled from each patient covering the necessary variables. Out of 100 patients 22% had raised creatinine kinase at 8 hours and 43% had raised creatinirie kinase after 24 hours following coronary angioplasty. Whereas 19% patients and 38% patients had raised creatinine kinase MB levels at 8 hours and 24 hours following the procedure respectively. No patient had rise of creatinine kinase or creatinine kinase MB more than 3 times of normal limits in the study. Among patients with raised CK-MB highest frequency was of diabetes mellitus, raised LDL levels, smoking and hypertension. Patients with raised CK-MB levels after 1[st] day of coronary angiography had diabetes mellitus [84%], raised LDL levels [79%], smoking [68%] and hypertension [58%]

Management of patients with acute myocardial infarction complicated by ventricular septal rupture - AFIC study

The aim of this study was to report management; peri-procedural and short term results of patients hospitalized with acute myocardial infarction [MI]complicated by ventricular septal rupture [VSR] considered high risk or unfit for surgical repair at AFIC-NIHD. Quasi experimental study Adult and paediatric cardiology departments of Armed Forces Institute of Cardiology / National Institute of Heart Diseases [AFIC/NIHD] from 1[st] January 2012 to 31[st] August 2013. We included 12 patients with post myocardial infarction VSR with mean age of 59 years [41-85 years], who underwent elective transcatheter closure. The entry criteria for trans-catheter closure after initial medical stabilization was 1] patients with ventricular septal rupture up to 20 mm size with significant left to right shunting [Qp/Qs >1.5] 2] defect anatomy and location thought to be suitable for device closure or otherwise considered high risk or unfit for surgical closure. The time from the onset of infarction to the index procedure ranged between 4 to 20 days [mean 10.83 days]. There were ten patients in acute phase [2 weeks or less] and two presented in sub-acute phase [> 2 weeks]. Ten patients were in NYHA class III and one each in class II and IV. A successful device implantation occurred in all patients except in one in whom second attempt failed. The defect size ranged 4-18 mm [mean 9.25 mm] and the devices ranging from 8-22 mm [mean 13.3 mm] were implanted. The procedure time ranged from 90-140 min [mean 105 min]. In all patients Qp/Qs was more than 2 and decreased to less than two after the procedure. Six surviving patients are in NYHA class II and doing well. One patient died one hour after the procedure whereas one patient died twelve hour after the closure because of re-infarction. One patient developed another VSR leak 3 days after the procedure and device closure was attempted again but the device could not be deployed. He subsequently died awaiting surgery. Primary trans-catheter closure of post-infarction ventricular septal rupture may be an alternative to surgery in patients with suitable anatomy and high risk or unfit for surgery

Procedural outcome of primary PCI inst-segment elevation myocardial infarction at Afic and Nihd Rawalpindi - Pakistan

To determine the procedural outcome of primary percutaneous coronary interventions [PCI] in ST segment elevation myocardial infarction. A quasi-experimental study. Armed Forces Institute of Cardiology and National Institute of Heart Diseases, a tertiary care cardiac institute from November 2011 to September 2013. Total 228 patients who underwent primary percutaneous intervention [primary PCI] were included in this study. A pre designed performa was prospectively filled which included demographic and procedural variables. Procedural success and in hospital mortality were recorded. The mean age was 59 +/- 10.88 years. There were 205 [89.9%] males, 80 [35.1%] patients were found to be diabetic, 47 [20.6%] hypertensive, and 90 [39.5%] patients were smokers. Family history of ischemic heart disease was positive in 51 [22.4] patients. Anterior, inferior and lateral myocardial infarction were present in 137 [60.1%], 90 [39.5%] and 1 [0.4%] patients respectively. The Median time from the onset of symptoms to the arrival in the hospital was 122.5 +/- 142.57 and median door to balloon time was 60 +/- 22.88 min. Left anterior descending [LAD] was the commonest infarct related artery accounting for culprit artery in 138 [60.5%] followed by right coronary artery [RCA] and left circumflex artery [LCX] in 72 [31.6%] and 18 [7.9%] cases respectively. Procedural success was achieved in 222 [97.4%] patients. Six [2.6%] patients died in the hospital. High success rate with low mortality rates can be achieved in our set up. However more studies and long term follow up is required to validate our results

Levels of serum vascular endothelial growth factor in type 2 diabetics with retinopathy

Ischemic retina in diabetic patients releases a number of chemical substances including vascular endothelial growth factor which leads to retinal vascular proliferation and blindness following rupture and bleeding of vessels. Strategies to control this action can considerably halt this process. To determine the relationship of various stages of diabetic retinopathy with the levels vascular endothelial growth factor in the serum of type 2 diabetic patients. Study type, settings and duration: This cross sectional analytical study was done over one year [2010-2011] in three major public sector hospitals of Peshawar. Patients and Methods: Adult patients of either gender having type 2 diabetes mellitus with proliferative or non proliferative retinopathy and those without retinopathy were selected for the study. Retinopathy was diagnosed on fundoscopy. Non-diabetic patients without retinopathy were selected as controls. Serum levels of vascular endothelial growth factor were done in patients and controls using ELISA. Serum vascular endothelial growth factor levels were significantly higher in all cases having retinopathy as compared to controls. These levels progressively increased with the gr ades of retinopathy. Levels were higher in females. Levels of vascular endothelial growth factor are raised in diabetic retinopathy and rising levels can alert the clinician in worsening of retinopathy so that preventive and therapeutic measures can be taken promptly. Policy message: Further larger scale studies are recommended on national level to pave way for the establishment of appropriate management paradigms for diabetic retinopathy through anti-VEGF treatment

Synovial sarcoma of the heart

A young male presented with dyspnoea and was found to have a diastolic murmur at the left lower sternal edge. Transthoracic and transoesophageal echocardiograms found a large mass attached to the tricuspid valve, which was projecting into the right atrium and the right ventricle. The mass was causing significant obstruction of the right ventricular inflow. Emergency surgery had to be performed because the patient developed severe vomiting [of unknown cause] leading to haemodynamic compromise. This condition was not responding to fluid resuscitation as there was obstruction to right ventricular inflow. Intraoperatively the mass was removed and the tricuspid valve was repaired. The histological and immunohistochemical examination of the excised tissue confirmed the rare diagnosis of synovial sarcoma of the heart. Postsurgical imaging showed no metastases. The patient received postoperative radio therapy and chemotherapy. The tumour recurred after 6 months and the patient succumbed to his illness and expired

Coronary artery disease in the elderly

The objective of our study is to assess the severity of coronary artery disease in the elderly and predict the safety outcome of coronary angiography. A cross sectional observational study. AFIC/NIHD Rawalpindi. February 2011 and August 2011. The study population included 100 elderly patients [age>60 years] undergoing coronary angiography. 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]. More than 70% stenosis in more than one coronary artery was considered as severe coronary artery disease. Our study cohort comprised of 100 consecutive subjects 82 [82.0%] men and 18 [18.0%] women with a mean age of 78.6 years [Range 70 years - 94 years]. 77 patients [77.0%] had severe coronary artery disease; 50 with triple vessel coronary artery disease [TVCAD] 1 with TVCAD with Left Main Stem Disease, 26 had double coronary artery disease [DVCAD]. 12 patients [12.0%] had moderate coronary artery disease with single vessel involvement [SVCAD], 6 patients [6.0%] had subcritical coronary artery disease with < 60% stenosis in any of the vessel while only 5 patients [5%] had a normal coronary angiogram. Patients of elderly age group have more severe CAD and coronary angiography is a relatively safe procedure.

Clinico-pathological profile of sinonasal masses: study of 90 cases

To determine the clinicopathological profile of sinonasal masses studied at a tertiary care hospital. This descriptive study was conducted at the department ofENT, Head and Neck Surgery, Postgraduate Medical Institute Lady Reading Hospital Peshawar from Sept. 2008 to Aug. 2010, with total duration of 02 years. After admitting the patients'a detailed history was taken and thorough examination of ear, nose, throat and neck was carried out. Necessary investigations were performed. After taking an informed consent all the patients were subjected to proper surgical treatment and specimens were examined by histopathologist. All these patients were followed for minimum of six months duration on monthly basis. This study included 90 cases constituting 49 male and 41 female, with male: female ratio of 1.2:1. The age of the patients ranged from 08-65 years with mean age of 33.13 + S.D 18.67 years. The complaints of these patients were left side nasal obstruction [43.33%], Epistaxis [34.44%] and headache [27.77%]. Incisional biopsy of sinonasal masses was taken in 31 cases [34.44%] while among the surgical procedure antrochoanal polypectomy was the commonest [31.11%]. Histopathological diagnosis was obtained and simple inflammatory polyp was the commonest finding [63.3%] followed by angiofibroma [11.11%]. It is concluded that sinonasal masses mainly present with nasal obstruction, nasal discharge and benign masses predominate. Benign sinonasal masses are best treated with surgical excision

Nitinol stents; deployed in the internal carotid arteries; geometric effects

Stents deployed in the carotid arteries cause significant geometric changes in the vessels, influencing the flexibility and torsion characteristics of the vessels, which are aggravated by the high degree of mobility in this area of the body. The influence of these physical characteristics on carotid blood flow could influence the long term performance of the deployed stents. To evaluate the geometric changes in the carotid arteries after deployment of self expanding nitinol stents. Settings: AFIC-NIHD. November 2003 to August 2008. 45 cases of carotid artery stenting [CAS] done. We selected cases where the stenting to the internal carotid artery [ICA] had been done across the bifurcation of the common carotid artery [CCA] with self expanding nitinol stents, and when DICOM videos that had pre and post stenting images in the same imaging projection were available for analysis. Based on the inclusion criteria 21 videos were selected and deemed fit for taking measurements. The measurement system proposed by Berkefeld et al which involved the measurement of the CCA-ICA [common carotid artery-internal carotid artery] angle and ICA-offset was used. These variables were measured using onscreen measuring software which can measure linear distances and angles after appropriate calibration for each image. We did not find any significant changes in the ICA-offset; significant changes in the CCA-ICA angle were noted

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

Diagnostic value of fine needle aspiration cytology in diagnosis of non-thyroidal neck masses

To determine the diagnostic value of fine needle aspiration cytology in the diagnosis of non-thyroidal neck masses. This descriptive study was conducted at the Department of ENT, Lady Reading Hospital Peshawar from January to December 2009. Hundred patients with non-thyroidal neck masses fulfilling the inclusion criteria were included in the study. Fine needle aspirations were performed by the same cytopathologist. The findings were TB 31%, metastatic lymph node 19%, reactive lymphadenopathy 9%, lymphoproliferative disease 11%, pleomorphic adenoma 8%, thyroglossal cyst 5%, carotid body tumour 4%, lipoma and branchial cysts were 3% each, sialolithiasis 2% and one case each of dermoid, sebaceous cyst, adenoid cystic carcinoma, Kikuchi's disease and Ewing's tumour. Correlation of FNAC with biopsy was for TB; true positive, 64.5%, true negative 29.03%, false positive 3.22%, false negative 3.22% and for metastatic lymph node true positive 57.89%, true negative 36.84%, false positive 5.26% and no case of false negative. The diagnostic yield of FNAC was for TB, accuracy, sensitivity, specificity, positive predictive value and negative predictive value were 93.54%, 95.23%, 90%, 95.23% and 90% respectively. Metastatic lymph nodes accuracy sensitivity, specificity, positive predictive value and negative predictive value were 94.73%, 100%, 87.5%, 91.66% and 100% respectively. Overall diagnostic value of FNAC in non-thyroidal neck masses with regard to accuracy, sensitivity, specificity, positive predictive value and negative predictive value were 90%, 90%, 77.42%, 90.41%, 90.41%, and 88.89% respectively. Fine needle aspiration cytology for non-thyroidal neck masses has equal diagnostic yield to open biopsy

Coronary artery anomalies; An AFIC/NIHD experience

Introduction: Congenital anomalies of the coronary arteries occur in 0.2% to 1.2% of the general population1. The incidence of various coronary anomalies and associated clinical, angiographic and hemodynamic findings have been cited in several internationally published clinical series4-8. To compare our experience with previously reported studies, we have reviewed clinical and angiographic findings for 50 adult patients with coronary artery anomalies. We surveyed the records of 5050 consecutive adult patients who had undergone coronary angiography. Armed Forces Institute of Cardiology and National Institute of Heart Disease [AFIC/NIHD] Rawalpindi. 1[st] Jan 2004 and 30th April 2005, and identified 50 adults with various coronary artery anomalies. 5050 reports were reviewed and 50 [0.9%] coronary artery anomalies were identified in 50 patients. Different anomalies identified are; both coronary arteries from right sinus of Valsalva [RSV]-[n = 1], both coronary arteries arising from the left coronary sinus [n = 4], single coronary arteries [n = 2], LCx from RSV/RCA [n=6], anterior descending artery arising from the right coronary sinus [n = 1], coronary artery fistulae [n = 4], separated origin of anterior descending and left circumflex coronary arteries [n = 25], and separate origin of conus/ RV branch [n = 7]. The initial course was retroaortic in all the circumflex arteries, interarterial in the right coronaries, and anterior in the anterior descending arteries. We conclude that adult congenital anomalies of the coronary arteries are not uncommon finding in a tertiary care cardiac center. Separate origin of LAD and LCx from LSV and left circumflex coronary artery arising from RSV/RCA are the most frequently diagnosed anomalies