Risk of Cardiac Arrhythmias Among Climbers on Mount Everest.

Importance: Arterial hypoxemia, electrolyte imbalances, and periodic breathing increase the vulnerability to cardiac arrhythmia at altitude. Objective: To explore the incidence of tachyarrhythmias and bradyarrhythmias in healthy individuals at high altitudes. Design, Setting, and Participants: This prospective cohort study involved healthy individuals at altitude (8849 m) on Mount Everest, Nepal. Recruitment occurred from January 25 to May 9, 2023, and data analysis took place from June to July 2023. Exposure: All study participants underwent 12-lead electrocardiogram, transthoracic echocardiography, and exercise stress testing before and ambulatory rhythm recording both before and during the expedition. Main Outcome: The incidence of a composite of supraventricular (>30 seconds) and ventricular (>3 beats) tachyarrhythmia and bradyarrhythmia (sinoatrial arrest, second- or third-degree atrioventricular block). Results: Of the 41 individuals recruited, 100% were male, and the mean (SD) age was 33.6 (8.9) years. On baseline investigations, there were no signs of exertional ischemia, wall motion abnormality, or cardiac arrhythmia in any of the participants. Among 34 individuals reaching basecamp at 5300 m, 32 participants climbed to 7900 m or higher, and 14 reached the summit of Mount Everest. A total of 45 primary end point-relevant events were recorded in 13 individuals (38.2%). Forty-three bradyarrhythmic events were documented in 13 individuals (38.2%) and 2 ventricular tachycardias in 2 individuals (5.9%). Nine arrhythmias (20%) in 5 participants occurred when climbers were using supplemental bottled oxygen, whereas 36 events (80%) in 11 participants occurred at lower altitudes when no supplemental bottled oxygen was used. The proportion of individuals with arrhythmia remained stable across levels of increasing altitude, while event rates per 24 hours numerically increased between 5300 m (0.16 per 24 hours) and 7300 m (0.37 per 24 hours) before decreasing again at higher altitudes, where supplemental oxygen was used. None of the study participants reported dizziness or syncope. Conclusion and Relevance: In this study, more than 1 in 3 healthy individuals experienced cardiac arrhythmia during the climb of Mount Everest, thereby confirming the association between exposure to high altitude and incidence of cardiac arrhythmia. Future studies should explore the potential implications of these rhythm disturbances.

Acute Myocardial Infarction in Women, a Study on Risk Factors, Angiographic Features and Outcomes.

BACKGROUND: Women with acute coronary syndrome are more likely to have cardiovascular disease risk factors and atypical symptoms as compared to men. In Nepal, there is a rising trend of Coronary Artery Disease and myocardial infarction in women. However, research on acute myocardial infarction in women is lacking. The aim of this study was to study the cardiac risk factors, clinical features, angiographic features, and outcome of acute myocardial infarction in Nepalese women admitted to Hospital. METHODS: This was a cross sectional study done at Shahid Gangalal National Heart Center Kathmandu from September 2016 to March 2017. Female patients admitted with a diagnosis of acute ST-segment elevation myocardial infarction or non-ST segment elevation myocardial infarction, who fulfilled the inclusion criteria were included in the study. The details of the patients, demographic profile, major clinical symptoms, major coronary artery disease risk factors, angiographic features and outcomes were recorded and assessed during the study period. Coronary angiography was done in 112 patients out of 178 patients. RESULTS: Out of 178 patients, 85.95 % had ST-segment elevation myocardial infarction and 14.05% had non-ST segment elevation myocardial infarction. The mean patient age was 62.53 ± 12.1. 26.4% patients were of age less than 55 years. Major risk factors were central obesity (94.61%), dyslipidemia due to low HDL (78.65%). hypertension (54.49%), smoking (54.49%) and type 2 diabetes (34.83%). The most common atypical symptoms were shortness of breath (35.39 %,) , nausea and vomiting (23. 6%) and epigastric pain (6.74%), Single vessel disease was found in 36%; double vessel disease in 26.3% and triple vessel disease in 28.9% of patients. The primary outcome of in- hospital mortality was 3.37 %. CONCLUSIONS: Our study showed that significant number of females had Coronary Artery Disease at early age. Among women with myocardial infarction in Nepal, obesity due to high waist to hip ratio was the most common risk factor followed by dyslipidemia due to low high density lipoproteins, smoking, hypertension, and diabetes. Atypical symptoms were also common findings. Single vessel disease was the most common lesion and left anterior descending artery was the most commonly involved vessel. Mortality was seen in ST-segment elevation myocardial infarction patients only.

Decentralization and Integration of Advanced Cardiac Care for the World's Poorest Billion Through the PEN-Plus Strategy for Severe Chronic Non-Communicable Disease.

Rheumatic and congenital heart disease, cardiomyopathies, and hypertensive heart disease are major causes of suffering and death in low- and lower middle-income countries (LLMICs), where the world's poorest billion people reside. Advanced cardiac care in these counties is still predominantly provided by specialists at urban tertiary centers, and is largely inaccessible to the rural poor. This situation is due to critical shortages in diagnostics, medications, and trained healthcare workers. The Package of Essential NCD Interventions - Plus (PEN-Plus) is an integrated care model for severe chronic noncommunicable diseases (NCDs) that aims to decentralize services and increase access. PEN-Plus strategies are being initiated by a growing number of LLMICs. We describe how PEN-Plus addresses the need for advanced cardiac care and discuss how a global group of cardiac organizations are working through the PEN-Plus Cardiac expert group to promote a shared operational strategy for management of severe cardiac disease in high-poverty settings.

Patterns of Perception of Cardiac Symptoms by Patients Presenting with ST-Segment Elevation Myocardial Infarction and their Knowledge of Coronay Artery Disease Risk Factors.

BACKGROUND: Proper knowledge regarding Coronary Artery Disease and their risk factors is essential for the early recognition of the disease and its presentation. This study was conducted to identify pattern of clinical symptoms and knowledge regarding Coronary Artery Disease risk factors among ST-Elevation myocardial infarction (STEMI) patients. METHODS: This cross-sectional, observational study was conducted among 340 ST-Elevation myocardial infarction patients in the inpatient Cardiology Department of Shahid Gangalal National Heart Centre Nepal, from November 2020 to February 2021. Baseline clinical characteristics, knowledge regarding Coronary Artery Disease risk factors, patterns of symptoms, and prehospital delay were collected and evaluated. RESULTS: In our study, 299 (87.9%) had typical ischemic chest pain during the symptom onset, however, only 81 (23.8%) perceived chest pain as cardiac disease, and 311 (91.5%) of the patients presented to the nearby health care center within the recommended time of less than 12 hours for the reperfusion therapy of ST-Elevation myocardial infarction. Perception of symptoms as a cardiac origin and typical chest pain were not significantly associated with earlier presentation. Also, the typical chest pain was not significantly associated with the perception of the symptom as a cardiac origin. The history of Coronary Artery Disease was considered as a Coronary Artery Disease risk factor by 184(54.1%) of the study population and 137(40.3%), 132(38.8%), 110(32.4%), 105(30.9%) and 71(20.9%) considered hypertension, smoking, age, obesity, and diabetes mellitus as a Coronary Artery Disease risk factor respectively. CONCLUSIONS: Though most patients presented with typical chest pain, identification of the chest pain as a cardiac origin and the awareness of the Coronary Artery Disease risk factors was low.

Prevalence of latent structural heart disease in Nepali schoolchildren.

BACKGROUND: The present study aimed to quantify the burden of structural heart disease in Nepali children. METHODS: We performed a school-based cross-sectional echocardiographic screening study with cluster random sampling among children 5-16 years of age. RESULTS: Between December 2012 and January 2019, 6573 children (mean age 10.6 ± 2.9 years) from 41 randomly selected schools underwent echocardiographic screening. Structural heart disease was detected in 14.0 per 1000 children (95% CI 11.3-17.1) and was congenital in 3.3 per 1000 (95% CI 2.1-5.1) and rheumatic in 10.6 per 1000 (95% CI 8.3-13.4). Rates of rheumatic heart disease were higher among children attending public as compared to private schools (OR 2.8, 95% CI 1.6-5.2, p = 0.0001). CONCLUSION: Rheumatic heart disease accounted for three out of four cases of structural heart disease and was more common among children attending public as compared to private schools.

Safety and Efficacy of Single vs Dual Antiplatelets Therapy After Atrial Septal Defect Device Closure.

BACKGROUND: Atrial septal defect device closure has become a standard procedure. Antiplatelet therapy is used to prevent thrombus formation in the device. There is no clear recommendation about the antiplatelets drugs. This study aims to evaluate the safety and efficacy of Aspirin vs (Aspirin +Clopidogrel) after device closure. METHODS: A cross-sectional study was conducted among all consecutive adult patients (?18 years) who underwent atrial septal defect device closure from May 2019 to April 2020 and meet the inclusion criteria were included. After successful ASD device closure patients were treated with ASA or combination of ASA and Clopidogrel for six months on physician discretion. Patients were followed up for six months to observe for Transient ischemic attack, Stroke, thrombus in the device, myocardial infarction, major bleeding, minor bleeding and increases in headache episodes compared to baseline. RESULTS: This study consisted of 130 patients: 65 in the Aspirin Group, and 65 patients in Aspirin and Clopidogrel group. There was no Transient ischemic attack, Stroke, Myocardial infarction, thrombus, major bleeding in both groups. There was no significant difference between two groups in ecchymosis; Aspirin group 4(6.1%) vs. aspirin and Clopidogrel group 3(4.6%) [Difference, 1.54% {95, % CI, -1.45%to 4.53%}]; P=0.648. There was no significant difference in increase in headache episodes compared to baseline for six months after the device closure in Aspirin Group 3(4.6%) VS Aspirin and Clopidogrel group 2 (3.0%) group [difference, 1.54% {95% CI, -1.45%to 4.53%}]; P=0.648. CONCLUSIONS: Our study suggests that single antiplatelet therapy with Aspirin is as safe and effective as aspirin and clopidogrel after device closure.

Mid-term outcome of children with latent rheumatic heart disease in eastern Nepal.

INTRODUCTION: Systematic echocardiographic screening of children in regions with an endemic pattern of rheumatic heart disease allows for the early detection of valvular lesions suggestive of subclinical rheumatic heart disease. The natural course of latent rheumatic heart disease is, however, incompletely understood at this time. METHODS: We performed a prospective cohort study of children detected to have echocardiographic evidence of definite or borderline rheumatic heart disease according to the World Heart Federation Criteria. RESULTS: Among 53 children found to have definite (36) or borderline (17) rheumatic heart disease, 44 (83%) children underwent follow-up at a median of 1.9 years (IQR 1.1-4.5). The median age of the children was 11 years (IQR 9-14) and 34 (64.2%) were girls. Among children with definite rheumatic heart disease, 21 (58.3%) were adherent to secondary antibiotic prophylaxis, 7 (19.4%) were not, information on adherence was missing in 2 (5.6%) children and 6 (16.7%) were lost to follow-up. Regression of disease was observed in 10 children (27.8%), whereas 20 children (55.6%) had stable disease. Among children adherent to secondary prophylaxis, seven (33.3%) showed regression of disease. Among children with borderline disease, seven (41.2%) showed regression of disease, three (17.6%) progression of disease, four (23.5%) remained stable and three (17.6%) were lost to follow-up. On univariate analysis, we identified no predictors of disease regression, and no predictors for lost to follow-up or non-adherence with secondary antibiotic prophylaxis. CONCLUSION: Definite rheumatic heart disease showed regression in one in four children. Borderline disease was spontaneously reversible in less than half of the children and progressed to definite rheumatic heart disease in one in five children. TRIAL REGISTRATION NUMBER: NCT01550068.

Effectiveness of Systematic Echocardiographic Screening for Rheumatic Heart Disease in Nepalese Schoolchildren: A Cluster Randomized Clinical Trial.

Importance: Echocardiographic screening allows for early detection of subclinical stages of rheumatic heart disease among children in endemic regions. Objective: To investigate the effectiveness of systematic echocardiographic screening in combination with secondary antibiotic prophylaxis on the prevalence of rheumatic heart disease. Design, Setting, and Participants: This cluster randomized clinical trial included students 9 to 16 years of age attending public and private schools in urban and rural areas of the Sunsari district in Nepal that had been randomly selected on November 17, 2012. Echocardiographic follow-up was performed between January 7, 2016, and January 3, 2019. Interventions: In the experimental group, children underwent systematic echocardiographic screening followed by secondary antibiotic prophylaxis in case they had echocardiographic evidence of latent rheumatic heart disease. In the control group, children underwent no echocardiographic screening. Main Outcomes and Measures: Prevalence of the composite of definite or borderline rheumatic heart disease according to the World Heart Federation criteria in experimental and control schools as assessed 4 years after intervention. Results: A total of 35 schools were randomized to the experimental group (n = 19) or the control group (n = 16). After a median of 4.3 years (interquartile range [IQR], 4.0-4.5 years), 17 of 19 schools in the experimental group (2648 children; median age at follow-up, 12.1 years; IQR, 10.3-12.5 years; 1308 [49.4%] male) and 15 of 16 schools in the control group (1325 children; median age at follow-up, 10.6 years; IQR, 10.0-12.5 years; 682 [51.5%] male) underwent echocardiographic follow-up. The prevalence of definite or borderline rheumatic heart disease was 10.8 per 1000 children (95% CI, 4.7-24.7) in the control group and 3.8 per 1000 children (95% CI, 1.5-9.8) in the experimental group (odds ratio, 0.34; 95% CI, 0.11-1.07; P = .06). The prevalence in the experimental group at baseline had been 12.9 per 1000 children (95% CI, 9.2-18.1). In the experimental group, the odds ratio of definite or borderline rheumatic heart disease at follow-up vs baseline was 0.29 (95% CI, 0.13-0.65; P = .008). Conclusions and Relevance: School-based echocardiographic screening in combination with secondary antibiotic prophylaxis in children with evidence of latent rheumatic heart disease may be an effective strategy to reduce the prevalence of definite or borderline rheumatic heart disease in endemic regions. Trial Registration: ClinicalTrials.gov Identifier: NCT01550068.

Hyperkalemia mimicking brugada pattern in electrocardiogram: A rare case report from Nepal.

Hyperkalemia is one of the dangerous complications of renal impairment (acute kidney injury or chronic kidney disease). Hyperkalemia may present with the electrocardiogram (ECG) changes as nonspecific repolarization abnormalities. Here, we report a case of AKI with hyperkalemia and the Brugada pattern of ECG, which reverted to normal after effective management of hyperkalemia. A 55-year-old male reported to the Emergency Department of National Academy of Medical Sciences (Bir Hospital) with injuries in his lower limbs and spine after he had met an accident two days back. He also had decreased urine output for the last one day. On physical examination, he had injuries in the spine and lower limbs. His laboratory investigations showed impaired renal function parameters with serum sodium 130 mEq/L and serum potassium of 7.3 mEq/L. His ECG was consistent with Brugada pattern. Patient was treated with 10% calcium gluconate, insulin and dextrose, salbutamol nebulization, and sodium polystyrene sulfonate till hemodialysis was initiated. Hyperkalemia and acidosis can manifest with the Brugada pattern in ECG. Thus, a careful evaluation of hyperkalemia and its treatment must be instituted in such an ECG pattern.

Rheumatic heart disease: pilot study for a population-based evaluation of prevalence and cardiovascular outcomes among schoolchildren in Nepal.

OBJECTIVES: To evaluate a protocol for a population-based programme targeting the prevention of rheumatic heart disease (RHD) progression by early echocardiographic diagnosis of valvular lesions and timely implementation of secondary prevention. DESIGN: Observational survey with a subsequent prospective cohort study. SETTING: Private boarding school in the urban area of the Sunsari district situated on the foothills of the Lower Himalayan Range in Eastern Nepal. PARTICIPANTS: Fifty-four unselected school-going children 5-15 years of age, 24 girls and 30 boys. PRIMARY OUTCOME MEASURE: Logistic feasibility of a large-scale population-based screening study using the echocardiographic criteria formulated by the World Heart Federation, with longitudinal follow-up of children with definite or borderline RHD in a prospective cohort study. RESULTS: Standardised interview, physical examination and screening echocardiography were performed in a three-staged process and took approximately 6 min per child. Socio-economic status was assessed using surrogate markers such as the occupation of the primary caregiver, numbers of rooms at home, car, television, cell phone and internet connection. Physical examination was focused on cardiac auscultation and signs of acute rheumatic fever and targeted echocardiography was performed by an independent examiner without knowledge of the clinical findings. Two children with evidence of borderline RHD were re-examined at B.P. Koirala Institute of Health Sciences and the indication for secondary antibiotic prevention was discussed with the parents and the children. At 6 months of follow-up, echocardiographic findings were stable in both children. Implementation of secondary antibiotic prevention was challenged by impaired awareness of subclinical RHD among parents and inadequate cooperation with family physicians. CONCLUSIONS: This pilot study shows that the methods outlined in the protocol can be translated into a large-scale population-based study. We learned that education and collaboration with teachers, parents and family physicians/paediatricians will be of key importance in order to establish a sustainable programme.