Depression and congestive heart failure: A large prospective cohort study from Pakistan.

OBJECTIVES: Evidence demonstrates the detrimental impact of depression in patients with congestive heart failure (CHF), however, large-scale prospective data from Low and Middle Income Countries (LMICs) is limited. We assessed the prevalence of depression in a large sample with CHF from Karachi, Pakistan, and the impact of depression on all-cause mortality, disability and health-related quality of life (QoL). METHODS: 1009 patients diagnosed with CHF were recruited from public hospitals in Karachi, Pakistan. Patients were screened for depression at baseline using the Beck Depression Inventory (BDI) and the diagnosis was confirmed using the Clinical Interview Schedule-Revised (CIS-R). Health-related QoL and disability were measured using the EuroQol (EQ-5D) and Brief Disability Questionnaire respectively at baseline and after a 6-month follow-up. RESULTS: A total of 670 (66%) patients were depressed at baseline and 821 participants completed 6-month follow up assessments (retention rate: 81%). At baseline, lower income (p < 0.001) and lower education level (p = 0.03) were associated with higher BDI scores. Higher BDI scores were associated with a history of depression (p < 0.001), higher NYHA class (p < 0.001), diabetes (p < 0.001), COPD (p = 0.007), renal disease (p < 0.001) and stroke (p = 0.02). 145 participants were deceased at 6-months. Regression analysis showed that at follow up, higher BDI scores in depressed participants were associated with higher all-cause mortality (OR 1.23 (95% CI: 1.11-1.36); p < 0.001). CONCLUSION: The rate of depression was high among Pakistani patients with CHF. Severity of depression correlated with increased mortality. Further research on controlled intervention trials in this population is warranted.

Peripartum cardiomyopathy: Frequency and predictors and indicators of clinical outcome.

OBJECTIVE: To determine frequency and prognostic factors of peripartum cardiomyopathy. METHODS: The prospective cohort study was conducted from April 2012 to September 2013 at Civil Hospital, Karachi. Cases were collected in the first year, and were then followed up for six months. On clinical and transthoracic 2-D M Mode echocardiography, cases of prepartum peripartum cardiomyopathy were detected. After necessary lab tests, cardiac opinion and treatment, pregnancy was terminated using caesarean section. At complete clinical recovery, the subjects were discharged to be followed up in cardiac and gynaecology clinics with current echocardiograph at 3rd and 6th month. SPSS 15 was used for data analysis. RESULTS: Out of 5742 deliveries, 22(0.38%) were cases of prepartum peripartum cardiomyopathy; the frequency being 3.8/1000 births. At 6-month follow-up, 14 (63.63%) cases recovered and 6(27.3%) did not. Two (9%) cases expired on 2nd and 16th day of delivery. On baseline or diagnostic echo, left ventricular ejection fraction and fractional shortening were statistically significant predictors of clinical outcome (p<0.05 each). Ejection fraction and fractional shortening were strong predictors of clinical outcome (p<0.05 each).During follow-up, left ventricular ejection fraction, fractional shortening, left ventricular internal dimension at diastole, and left ventricular internal dimension at systole (LVISd) were statistically significant indicators of clinical outcome (p<0.05 each). CONCLUSIONS: Baseline and follow-up echo was the best tool for prognosis. Baseline left ventricular ejection fraction and fractional shortening were significant predictors of clinical outcome.

Variation in admission rates of acute coronary syndrome patients in coronary care unit according to different seasons.

OBJECTIVE: Environmental stresses, especially extreme cold and hot weathers, have tendency to have more admissions for acute coronary syndromes. Due to scarcity of local data, we studied the variation in patient admission rates with acute coronary syndrome according to different seasons. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Coronary Care Unit, Civil Hospital and Pakistan Steel Hospital, Karachi, from January 2011 to December 2011. METHODOLOGY: The study group comprised consecutive patients with acute coronary syndrome (unstable angina, Non ST-Elevation Myocardial Infarction (NSTEMI), ST-Elevation Myocardial Infarction (STEMI) admitted to the coronary care unit. Patients with stable angina and valvular heart disease were excluded. Data was analyzed for admission according to different seasons, (winter, spring, summer and autumn). RESULTS: The mean age of the 428 cases was 48.5 ± 10.4 years (range 27 to 73 years). Among the study group, 261 (61%) and 167 (39%) cases were male and female respectively. ST-elevation myocardial infarction, non ST-elevation myocardial infarction and unstable angina were present in 206 (48%), 128 (30%) and 94 (22%) respectively. Among the 428 patients, 184 (43%) cases had hypertension, 133 (31%) cases were smokers, 103 (24%) cases had dyslipidemia and diabetes mellitus and 08 (2%) cases had history of premature coronary artery disease. The number of patients admissions with acute coronary syndrome tended to change with sudden change in season. It increased in Winter 158 (36.9%) and Summer 130 (30.3%) in comparison to Spring 80 (18.69%) and Autumn 60 (14.02%) season. CONCLUSION: It was found variation in admission rates of acute coronary syndrome patients according to different seasons. The number of admissions not only increased in the cold season (winter) but also in hot season (summer) with sudden changes in temperature.