2021 Asia Pacific Heart Rhythm Society (APHRS) practice guidance on atrial fibrillation screening.

In this paper, the Asia Pacific Heart Rhythm Society (APHRS) sought to provide practice guidance on AF screening based on recent evidence, with specific considerations relevant to the Asia-Pacific region. A key recommendation is opportunistic screening for people aged ≥65 years (all countries), with systematic screening to be considered for people aged ≥75 years or who have additional risk factors (all countries).

Cross Over: A Reliable Maneuver In The Confirmation Of Atrioventricular Nodal Reentrant Tachycardia Ablation.

BACKGROUND: Atrioventricular nodal re-entrant tachycardia (AVNRT) is still the most common presentation to our electrophysiology laboratory for ablation. The aim of this study is to document the confirmative value of cross over manoeuvre in successful AVNRT ablation. METHODS: This study was conducted in Hayat Abad Medical complex Peshawar June 2006 to October 2015. In all patient with AVNRT, Dual-nodal pathway physiology confirmed by programmed atrial pacing of eight Tran with an extra beat by 10 millisecond (ms) decrement and at least Atrial HIS (A-H) interval prolongation of 50 ms. The dual pathway was further confirmed by cross over manoeuvre. Slow pathway potential identified and radiofrequency ablation (RFA) energy applied at 60 temperatures and 30 powers in Left Anterior Oblique (LAO) projection. Post ablation absence of cross over documented with and without isoproterenol and patient followed for any complication or recurrence. RESULTS: Total 567 patients studied with mean age 36.56±12.16 and male to female ratio 1:1.4 with presentation of supraventricular tachycardia (SVT). Slow pathway was successfully modified and statistically no significant complication or recurrence documented. CONCLUSIONS: Failure to cross over reliably excludes any conduction over the slow pathway and so recurrence of AVNRT.

Permanent Pace Maker Implantation Through Axillary Vein Approach.

BACKGROUND: Device implantation is an integral part of interventional cardiology particularly electrophysiology. In this study, we are going to shear our experience of device implantation technique at electrophysiology department Hayatabad Medical Complex, Peshawar. METHODS: The study was conducted from June 2011 to December 2015. Axillary vein was used to implant the devices but in some cases when this rout was not convenient due to any reason then subclavian vein was entered through the Seldinger technique. Fluoroscopy time was less than 10 minutes and total procedure time was not more than 45 minutes. Electric cautery was used only in two cases. Pressure dressing was used in a few cases. RESULTS: Total numbers of permanent pacemakers (PPM) remain 800 during the study period. There were 450 single chamber pacemakers and 350 dual chambers pacemakers. No case of any major bleeding was documented and in very few cases there was mild ooze from the procedure site after the operation which was tackled with pressure dressing. Four cases of pneumothorax were noted during the study period and in three cases chest intubation were done and one patient was kept on conservative management. Patient were followed after one moth of discharge from the hospital and then yearly. Eight cases of lead dislodgment were documented during the study period. CONCLUSIONS: Axillary vein approach for implantation of permanent pacemakers is a safe and less time-consuming technique.

TEMPORARY PACE MAKERS IMPLANTATION: DO WE NEED FLUOROSCOPY?

BACKGROUND: Temporary pace maker (TPM implantation is done mostly in emergency with assistance of fluoroscopy. Fluoroscopy has various constrains which may delay the procedure at different occasion. We are going to share our experience in TPM implantation without fluoroscopy from internal jugular vein. METHODS: The case series study was conducted in Hayatabad Medical complex Peshawar from January 2011 to November 2011. Internal jugular vein was cannulated with 6 French sheaths in the supra-clavicular region with modified Seldinger technique. TPM wire connected to the TPM device and advanced in the sheath to the right ventricle. Position was confirmed from captured beat on monitor. There was no need of repositioning and lead remains stable. RESULTS: Total 122 TPM leads were implanted in the study period. All patients were implanted from internal jugular vein. There were 71 male and 51 female patients. Among these patients 55 were in hemodynamically unstable state. The average time of implantation was less than 10 minutes. There was failure in one case. So the overall success rate was 99.180%. CONCLUSION: TPM implantation from the internal jugular vein even without fluoroscopy is safe, less time consuming and convenient.

Lead erosion in permanent pacemaker: a cumbersome complication.

BACKGROUND: Lead erosion is one of the troublesome complications which are very difficult to treat and most of the time leads to device explanation and replacement prematurely. METHODS: From 2005 to 2011, total 415 pacemakers were implanted in our cardiology department at Hayatabad Medical Complex Peshawar. The patients were followed regularly at six month interval or more frequently in case there were complications. At every visit we inspected the wound site, electrocardiography was done and device was analyzed with compatible programmer for the device. If there was soreness at the site of implantation, patient was seen more frequently and if there was erosion of skin, wound was reopened margin refreshed and wound closed. Initially we closed the wound in two layers after reopening but we got repeated erosion with this method and so we buried the leads sub-muscularly as change strategy which again proved unsuccessful. Results: During the six years study about 415 permanent pacemakers were implanted. During this time period, we received: three lead erosion, which were repositioned. There were recurrence in two cases and they were again subjected to procedure with a change strategy; by burying the leads in muscles, which proved unsuccessful. CONCLUSION: Leads erosion can be prevented by carefully burying leads in three layers first in muscle followed by subcutaneous tissue and then closing the wound by suturing the skin during initial implantation.

Echomorphology of cardiomyopathy: review of 217 cases from 1999 to 2010.

OBJECTIVE: To study echocardiogram features of different types of cardiomyopathy presenting over a 12 year period at a single centre in Peshawar. METHODS: The series comprised a retrospective review of 13,788 consecutive echocardiograms carried out at the Muhammadi Hospital International Medical Research Centre, Hayatabad, Peshawar, from January 1999 to December 2010. Patients were split into two: Group I with paeditaric and adolescent cases (0-18 years) and Group II with adults (> 18 years). In the adult group, women with peripartum cardiomyopathy were subdivided into two groups of 18-30 years and 30 to 44 years. Standard Echo B and M modes and Doppler parameters were recorded to ascertain the diagnoses of common primary and secondary cardiomyopathies. Patients with myocarditis with chambers' dilatation and global dysfunction, and cardiopathy associated with major cardiovascular diseases were excluded. SPSS 14 was used for statistical analysis. RESULTS: Cardiomyopathy was diagnosed in 217 (1.57%) cases. There were 144 (66%) cases of dilated cardiomyopathy with a mean age of 13 +/- 14.8 years; 17 (8%) cases of hypertrophic cardiomyopathy with a mean age of 12 +/- 11.5 years; and 7 (3%) cases of restrictve cardiomyopathy with a mean age of 31 +/- 7.8 years. Primary cardiac amyloidosis was confirmed in 9 (4%) cases, and peripartum cardiomyopahty in 25 (11%) females. Rare subtypes were found in 15 (7%) cases. CONCLUSION: DCM was the most frequently diagnosed subtype of cardiomyopathy followed by HCM in both the adult and paediatric age groups.

Frequency of depression in patients with chronic heart failure.

UNLABELLED: Heart failure is a prevalent debilitating disease of poor prognosis in which heart cannot fill with or eject the sufficient amount of blood that is required due to structural or functional cardiac disorder. Depression is 4-5 times as common in heart failure (HF) patients as in the general population, and it might confer a higher risk of developing HF and negatively affect prognosis in established HF. OBJECTIVE: To determine the frequency of depression among patients presenting with chronic heart failure. METHODS: This descriptive cross sectional study was conducted in cardiology department Hayat Abad Medical Complex Peshawar from November 2011 to April 2012. In this study a total of 121 patients were observed by using 13% proportion of depression in heart failure, 95% confidence level and 6% margin of error, under WHO software for sample size determination. RESULTS: Mean age was 55 +/- 1.26 years. Sixty-eight percent patients were male and 32% were female. Fifteen percent patients had chronic heart failure for less than 1 year, 37% had chronic heart failure for 2-3 years and 48% patients had chronic heart failure for 3-4 years. Seventy percent patients had HADS score < 11 and 30% had HADS scored of > 11. Thirty percent patients had depression in chronic heart failure while 70% did not have depression in heart failure. CONCLUSION: Depression is common among CHF patients. Severe depression is more frequent than mild depression.

Comparison of effect of locally available brands of clopidogrel on platelet aggregation in patients with coronary artery disease.

BACKGROUND: Anticoagulant effect of clopidogrel is of utmost importance in coronary artery disease, especially in prevention of coronary stent thrombosis. Recently, many new local brands of clopidogrel have been launched, with unknown efficacy. This study was conducted with the aim to compare two locally prepared clopidogrel brands, in terms of the effect of a loading dose of 600 mg on inhibition of platelet aggregation in patients with coronary artery disease. METHODS: This was a double blind randomised study. Sample population consisting of 35 patients, were admitted at Lady Reading Hospital, Peshawar, for the management of coronary artery disease. Baseline platelet aggregation of all these patients was measured. These patients were divided in two groups randomly. Group-A consisting of 18 patients was given brand 'A' clopidogrel 600 mg, while Group-B consisting of 17 patients was give brand 'B' of clopidogrel 600 mg. The platelet aggregation of both groups was then measured at baseline, and at 2, 4, and 6 hours after taking the loading dose of 600 mg. RESULTS: Platelet aggregation time at baseline in Group-A was 2.61 +/- 2.28 sec. and in Group-B it was 2.24 +/- 1.52 sec. (p = 0.57). After 2 hours of clopidogrel administration in Group-A the platelet aggregation time was 1.44 +/- 1.58 sec. and in Group-B it was 1.53 +/- 1.107 sec. (p = 0.85). Platelet aggregation time after 4 hours in Group-A was 0.28 +/- 0.57 sec. and in Group-B 1.06 +/- 1.03 sec. (p = 0.009), and after 6 hours it was 0.00 +/- 0.00 sec. in Group-A and in Group-B it was 0.59 +/- 0.71 sec. (p = 0.001). CONCLUSION: The two brands of clopidogrel had a significant difference in their effect on inhibition of platelet aggregation. Different brands of clopidogrel may not be equally effective.

Frequency and predictors of renal artery stenosis in patients with coronary artery disease.

BACKGROUND: Renal artery stenosis (RAS) is a common finding in patients undergoing coronary angiography. We designed this study to look for the frequency and any predictors of renal artery stenosis in patients with coronary artery disease (CAD). METHODS: A total of 201 consecutive patients with CAD confirmed by coronary angiography underwent an abdominal aortogram in the same sitting to screen for RAS. Patient demographics and co-morbidities were analysed for any association with RAS. RESULTS: Forty-one of the patients were female (20.4%); ninety patients were hypertensive (44.8%); 49 patients (24.4%) were smokers; 19 patients (9.5%) had renal insufficiency; 88 patients (43.8%) had high cholesterol levels; 44 patients (21.9%) were diabetic. Thirty-two patients (15.9%) had single coronary artery disease, 59 patients (29.4%) had two vessel disease, and 110 patients (54.7%) had three vessel disease. Significant renal artery stenosis (> or = 50% stenosis) was present in 26 patients (12.9%). Among the variables studied, only female gender was found to be associated with a higher frequency of renal artery stenosis (24.39% vs 10.0%, p = 0.01). CONCLUSIONS: The frequency of renal artery stenosis in patients with coronary artery disease is 12.9%. Female gender is associated with a higher frequency of renal artery stenosis in patients with CAD.

Pattern of coronary artery disease with no risk factors under age 35 years.

BACKGROUND: Coronary artery disease (CAD) is no more deemed to be an ailment of the 4th or 5th decade; rather an earlier age incidence is not infrequently encountered in our population. However, there are a few data regarding CAD in young adults, and much about its underlying pathology still remains undetermined. The objective of this study was to delineate the coronary arterial disease pattern in adults under the age of 35 years, but having no known coronary risk factors. METHODS: This prospective study was conducted at the Cardiology Departments of all 3 public sector tertiary care hospitals in Peshawar from Jun 2008 to Dec 2009. After having excluded the traditional risk factors for CAD, patients under the age of 35 years with objective evidence of CAD were subjected to percutaneous coronary angiography. RESULTS: Out of a total of 104 patients, 85 (81.73%) patients were men, and 19 (18.27%) were women. The mean age of the whole group was 32.66 +/- 3.237 (22-35) years. Significant CAD (> 50% diameter narrowing of at least one major coronary artery) was found in 87 (83.7%) patients while 17 (16.3%) patients had non-atherosclerotic coronary artery disease, including 12 (11.53%) patients having normal coronary arteries, 1 (1%) patient had anomalous origin of right coronary artery (RCA), 1 (1%) patient had coronary arteritis, 2 (1.92%) patients had coronary artery ectasia, and 1 (1%) patient had a myocardial bridge over left anterior descending artery (LAD). Among the patients with significant CAD, the prevalence rate of one, two and three vessel disease was 54 (51.9%), 22 (21.2%) and 11 (10.6%) respectively. Almost 50% of the lesions occurred in LAD followed by 25% in RCA and 20% in circumflex, while only one patient (1%) had isolated significant CAD of left main coronary artery. Osteal segments were involved in 10%, proximal in 61%, mid in 21% and distal segments in 7% of the lesions. CONCLUSION: In the younger age group, CAD is mostly a disease of men, single vessel CAD predominates with LAD involvement mostly, predominant osteal to proximal segment involvement of vessels, and a much higher incidence of normal coronaries and non-obstructive CAD is met with.

Prevalence of hypertension among obese and non-obese patients with coronary artery disease.

BACKGROUND: Globally, obesity is now recognised as an epidemic. The degree of obesity is proportional to the rate of development of cardiovascular diseases, hence, resulting in a dramatic increase in morbidity and mortality. Apart from obesity, hypertension is another well recognised risk factor contributing to coronary artery disease (CAD). The precise prevalence of obesity-related hypertension varies with age, race and gender; and is yet unknown in our population. The objective of this study was to determine the prevalence of hypertension in obese and non-obese patients with diagnosed CAD. METHODS: This hospital based descriptive study was conducted in Cardiology Department of Postgraduate Medical Institute, Lady Reading Hospital, Peshawar from 15th March 2007 to 30th May 2008. A total of 200 patients with diagnosed CAD were enrolled, 100 were found obese and 100 non-obese. RESULTS: Among these, a total of 111 (55.5%) were found to be hypertensive, 66 (59.46%) of these were obese and 45 (40.54%) non-obese (p=0.003). CONCLUSION: Obese patients with CAD had significantly more frequent hypertension.

Myocardial infarction in young versus older adults: clinical characteristics and angiographic features.

BACKGROUND: Coronary artery disease is now frequently encountered in young adult population. However, being a relatively uncommon entity, not many studies are available in this regard. Therefore, the present study was designed to evaluate the clinical characteristics and angiographic features of patients less than 40 years of age with a history of myocardial infarction and compare them to patients older than 40 years. METHODS: A total of 281 patients who underwent coronary angiography from April, 2009 to December, 2009, were included in this study. The patients were divided into two groups on the basis of age. Group A included patients 40 years of age or younger. Group B included patients older than 40 years. Both the groups were compared with respect to gender, hypertension, diabetes mellitus and extent and severity of coronary artery disease as assessed on coronary angiography. RESULTS: Of the total 281 patients, 45 (16%) were < or =40 years old (Group-A) and 236 (84%) were older than 40 years (Group-B). There was no significant difference between the two groups with respect to the risk factors like gender, hypertension and diabetes mellitus. On coronary angiography, the two groups neither differed in the number of totally occluded vessels, nor in the severity of the culprit lesion. There were only 3 patients in group-A (6.7%) and 5 patients in group-B (2.1%) with normal coronaries (p=NS). Majority (60%) of the patients in group-A had no significant disease or single vessel disease while majority (69%) of the patients in group-B had two or more vessels involved (p<0.001 ). As far as the number of lesions in the coronary arteries is concerned, 62.3% patients had 2 or lesser lesions in group-A while 68.6% patients in group-B had three or more lesions (p=0.001). CONCLUSION: These data suggest that in our study, young patients with MI do not have significantly high prevalence of normal coronaries compared to older patients. Young patients are similar to the older patients with respect to severity of CAD. Lesser number of coronaries is involved and there is lesser number of lesions per patient in young patients compared to older ones.

Electrical storms and their prognostic implications.

BACKGROUND: Prevention of sudden cardiac death has always been a challenge for electrophysiologists and to date, automatic implantable cardiovertor defibrillator (AICD) is found to be the only remedy. This device delivers an intracardiac shock whenever it senses a fatal ventricular arrhythmia in order to achieve sinus rhythm. If the delivery of these intracardiac shocks becomes frequent, the situation is declared as an electrical storm. This article deals with the frequency, precipitating factors and prevention of electrical storms. METHODS: One hundred and ten episodes of electrical storms (a total of 668 shocks) were retrospectively analysed in 25 recipients of automatic implantable cardioverter defibrillators. ECG, echocardiography, serum electrolytes, urea and creatinine were done for all the patients, and they were hospitalized for a minimum of 24 hours. RESULTS: During the 3 year study period, all the 25 patients with an implantable cardiovertor defibrillator, on an average, received one shock per two years. However, 12 out of these 25 patients (50%) had more than two shocks within 24 hours. Most of these patients with electrical storms were having active ischemia, electrolytes imbalances or renal failure. CONCLUSION: Electrical storms are common in patients with coronary artery disease with impaired left ventricular functions. Ischemia, electrolytes imbalances and renal failure predispose to the electrical storms. Electrical Storms are predictors of poor prognosis.

Patterns of presentation of chronic ischemic heart disease with and without previous myocardial infarction.

BACKGROUND: The prevalence of Ischemic Heart Disease (IHD) is on the rise, from increasing lifespan of population and availability of better medical facilities. We studied chronic IHD cases with and without previous myocardial infarction, in Hazara, NWFP, Pakistan to evaluate left ventricular (LV) dysfunction, wall motion abnormalities and complications of IHD. METHODS: All patients presenting with history of chest pain in Medical 'C' Unit, Ayub Teaching Hospital, Abbottabad from June 2004 to May 2005 were included in the study. Patients with non-cardiac chest pain were excluded from the study. Cases with congenital and rheumatic heart disease, cardiomyopathies, unstable angina and acute MI were excluded. Patients with IHD with or without myocardial infarction (MI) were studied for left ventricular dysfunction (ejection fraction, left atrial size, E/A ratio), wall motion abnormalities and complications of IHD (Mitral regurgitation, Ventricular Septal Defect (VSD), LV aneurysm, LV clot). Clinical and echocardiographic evaluation was done in each case. RESULTS: Out of 183 cases of chronic IHD, 123 patients were without previous MI and 60 had had previous MI. Ejection fraction (EF) was 45% +/- 15 in the group without MI and 35 +/- 11% in cases with MI. Left Atrium (LA) size was 35 +/- 6 mm and 39 +/- 4 mm in the two groups respectively. LV diastolic dysfunction was seen in 17% in the first and 24% in the second group respectively. Global hypokinesia was seen in 8% and 17% in the 2 groups respectively. Regional Wall Motion Abrormality (RWMA) was observed in 12% in patients without MI and in 58% cases with MI. Mitral regurgitation was seen in 10 and 20% in the 2 groups respectively LV clots, VSD, LV and aneurysm were seen in 8.4, 5, and 6.5% respectively, only in cases with previous MI. CONCLUSION: LV dysfunction, wall motion abnormalities and mitral regurgitation were more common in IHD cases with previous heart attack.

Radiofrequency catheter ablation for supraventricular tachycardias: experience at Peshawar.

BACKGROUND: Drug therapy is mostly employed in the management of supraventricular tachycardias (SVTs). However, radiofrequency catheter ablation has been found to be highly effective and safe in the treatment of SVTs. The current study is aimed at sharing our experience of 320 patients who presented with SVTs, and were treated with radiofrequency catheter ablation. METHODS: This descriptive study was carried out in the Cardiac Electrophysiology Laboratory of Lady Reading Hospital, Peshawar from October 2006 to December 2009. Standard 4-wire electrophysiological study was carried out to identify the mechanism of SVT in 320 consecutive patients. Radiofrequency catheter ablation was used to interrupt the tachycardia circuit. RESULTS: Out of a total 320 patients who underwent electrophysiologic study, 168 were found to have atrioventricular nodal re-entry as underlying mechanism; 121 patients were having accessory pathway responsible for re-entry (of these 95 presented with orthodromic reciprocating tachycardia and 26 as antidromic reciprocating tachycardia); 19 patients were having focal atrial tachycardia, 4 atrial fibrillation and 8 atrial flutter as the underlying cause for SVT. Radiofrequency catheter ablation was used with an overall success of 94% and a complication risk of complete AV block in 0.3% and recurrence rate of 3%. CONCLUSION: Radiofrequency catheter ablation is safe and highly effective mode of treatment of SVTs.