Objectives: Aim of this study was to identify electrocardiographic predictors of electrophysiological study (EPS)-confirmed concealed left-sided accessory pathways in patients with narrow-complex tachycardia and to develop and internally validate an ECG-based prediction score. Methodology: This cross-sectional diagnostic accuracy and prediction-model development study included 290 consecutive adults undergoing EPS for narrow-complex tachycardia. Twelve-lead ECGs recorded during tachycardia were independently evaluated by two electrophysiologists blinded to EPS findings. Candidate ECG predictors included RP interval, pseudo-R wave in V1, pseudo-S waves in the inferior leads, ST-segment depression, P-wave morphology, and heart rate. The primary outcome was an EPS-confirmed concealed left-sided accessory pathway. Results: Among 290 patients, 238 (82.1%) had atrioventricular nodal reentrant tachycardia (AVNRT), 29 (10.0%) had left-sided atrioventricular reentrant tachycardia (AVRT), 12 (4.1%) had right-sided AVRT, and 11 (3.8%) had non-inducible tachycardia. Absence of a pseudo-R wave in V1 was independently associated with a concealed left-sided accessory pathway (adjusted OR 16.14, 95% CI 1.95–133.27; p=0.010), as was an intermediate RP interval (>90 ms but RP < PR; adjusted OR 13.72, 95% CI 4.56–41.28; p<0.001). ST-segment depression and heart rate >200 beats/minute were retained in the exploratory CLAP score but did not reach statistical significance in the multivariable model. The resulting 0–6-point CLAP score assigned 2 points each for intermediate RP interval and absence of pseudo-R wave in V1 and 1 point each for ST-segment depression and heart rate >200 beats/minute. At a cutoff of ≥4, the score demonstrated 79.31% sensitivity, 88.51% specificity, 43.40% positive predictive value, and 97.47% negative predictive value. Discrimination across the complete score range was high (AUC 0.938, 95% CI 0.902–0.974), with an optimism-corrected AUC of 0.938, calibration intercept of 0.012, and calibration slope of 0.983 after bootstrap internal validation. Conclusion: Selected ECG characteristics recorded during narrow-complex tachycardia were associated with EPS-confirmed concealed left-sided accessory pathways. The preliminary CLAP score demonstrated promising discrimination and internal calibration in this single-center cohort.
Objectives: To assess cardiovascular risk factors among undergraduate medical students and evaluate their association with family history of cardiovascular disease (CVD). Methodology: A cross-sectional analytical study was conducted at Dow University of Health Sciences from December 2025 to February 2026. A total of 179 undergraduate medical students aged ≥18 years were recruited using purposive sampling. Data were collected using a structured proforma assessing demographic characteristics, family history variables, lifestyle behaviors, anthropometric measurements, and clinical parameters. Anthropometric assessment included body mass index (BMI), waist circumference, and neck circumference, while clinical assessment included blood pressure, pulse rate, random blood glucose, and total cholesterol levels. Participants were stratified according to the presence or absence of family history of CVD. Results: Among the 179 participants, 44.1% reported a positive family history of CVD. Students with family history of CVD demonstrated significantly higher weight, pulse rate, waist circumference, neck circumference, cholesterol levels, and random blood sugar levels compared to those without family history (p<0.05). Lifestyle-related risk factors, including physical inactivity, reduced sleep duration, and smoking exposure, were also more common among participants with family history of CVD. Multivariable regression analysis demonstrated significant associations between the cardiovascular risk profile and age (OR=1.22; 95% CI: 1.08–1.37), pulse rate, cholesterol, random blood glucose, known hypertensive status, family history of hypertension, family history of smoking, physical inactivity, and reduced sleep duration (all p<0.05). Gender did not demonstrate a statistically significant association. Conclusion: Undergraduate medical students demonstrated clustering of metabolic and lifestyle-related cardiovascular risk factors, particularly among individuals with a positive family history of CVD. These findings emphasize the importance of early screening, lifestyle modification, and preventive cardiovascular health strategies in young medically literate populations.
Objectives: To determine the association between glycated hemoglobin (HbA1c) levels and angiographic coronary artery disease (CAD) complexity, assessed using the SYNTAX score, among nondiabetic patients presenting with acute coronary syndrome (ACS) and angiographically significant obstructive CAD. Methodology: This analytical cross-sectional study with prospective data collection was conducted at the Choudhary Pervaiz Elahi Institute of Cardiology, Multan, Pakistan, from 1 June to 30 November 2025. A total of 183 patients with ACS and angiographically significant obstructive CAD were included through consecutive sampling. Patients with established diabetes or HbA1c ≥6.5% were excluded. HbA1c was analyzed continuously and categorized as normal (<5.7%) or prediabetes (5.7–6.4%). Angiographic CAD complexity was assessed using the original anatomical SYNTAX score. Spearman's rank correlation was used for the primary unadjusted association, while multivariable linear regression assessed the association between HbA1c and SYNTAX score after adjustment for age, sex, obesity, hypertension, smoking, dyslipidemia, family history of premature CAD, and ACS subtype. Results: Of the 183 participants, 125 (68.3%) were male. The mean HbA1c was 5.56 ± 0.51%, and the median SYNTAX score was 20 (IQR 7). HbA1c demonstrated a strong positive correlation with SYNTAX score (Spearman's ρ = 0.742, 95% CI 0.669–0.801; P <0.001). Patients with prediabetes had significantly higher median SYNTAX scores than those with normal HbA1c [22 (IQR 20–25) vs. 17 (IQR 15–19); P <0.001]. In multivariable analysis, HbA1c remained positively associated with SYNTAX score (B = 7.577, 95% CI 6.469–8.685; P <0.001), with an adjusted R² of 0.512. Conclusion: Higher HbA1c levels were significantly associated with greater angiographic CAD complexity among nondiabetic patients presenting with ACS and established obstructive CAD. This association persisted after adjustment for measured clinical covariates. However, the cross-sectional design does not establish temporality, causality, or clinical predictive utility. Larger multicenter prospective studies are required to determine whether HbA1c provides incremental prognostic value beyond established cardiovascular risk factors.
Objectives: Patients undergoing coronary artery bypass grafting (CABG) require intensive lipid lowering as part of secondary prevention. However, real-world achievement of guideline-recommended ≥50% LDL-C reduction with low-dose statin therapy remains uncertain. Aim of this study was to determine the proportion of patients achieving ≥50% LDL-C reduction and to assess the magnitude of LDL-C reduction over time among post-CABG patients receiving 20 mg dose of statins. Methodology: This retrospective cohort study included 170 post-CABG patients receiving low-dose statin therapy. LDL-C levels were recorded at baseline and at 3, 6, and 12 months. The primary outcome was the proportion of patients achieving ≥50% LDL-C reduction at each time point. Within-subject changes over time were assessed using the Friedman test, with post-hoc pairwise comparisons conducted using Wilcoxon signed-rank tests with Bonferroni correction. Results: Median LDL-C reduction increased progressively from 16.3% (IQR: 10.7–21.0) at 3 months to 31.0% (IQR: 19.6–35.4) at 6 months and 45.9% (IQR: 25.7–50.6) at 12 months. Differences across time points were statistically significant (Friedman χ² = 423.9, p < 0.001; Kendall’s W = 0.836). No patients achieved ≥50% LDL-C reduction at 3 or 6 months, whereas 28.8% (95% CI: 22.5–36.1) achieved this target at 12 months. Mean LDL-C declined from 152.9 ± 20.6 mg/dL at baseline to 94.7 ± 27.6 mg/dL at 12 months. Conclusion: LDL-C reduction following CABG with low-dose statins is progressive over time; however, achievement of ≥50% reduction is limited within the first year. These findings highlight the need for closer monitoring and potential treatment intensification.
Cognitive impairment, frailty, and cardiovascular disease (CVD) are often approached as separate clinical problems. However, the recent American College of Cardiology (ACC) Scientific Statement presents a more integrated perspective, emphasizing their convergence in older adults and their close relationship with biological aging [1]. This framework is particularly relevant to Pakistan, where cardiovascular services increasingly encounter older patients with multimorbidity, delayed presentation, limited access to rehabilitation, and reduced functional reserve. The central message is important: chronological age alone is an inadequate measure of cardiovascular vulnerability, treatment tolerance, and recovery potential. Clinical assessment should increasingly consider biological age—the cumulative physiological and functional consequences of health and disease across the life course [1-3]. The Central Illustration, “Impact of Health Trajectory on Biologic Age,” provides a useful framework for translating geroscience into cardiovascular practice. Two individuals of the same chronological age may have markedly different biological ages because of differences in lifelong exposure to hypertension, diabetes, obesity, physical inactivity, poor diet, inflammation, vascular injury, and other adverse health determinants [2-5]. Biological aging therefore reflects more than the passage of time; it represents the progressive accumulation of molecular, cellular, physiological, and functional changes that influence resilience and vulnerability [2,3]. From a cardiovascular perspective, successful prevention should consequently extend beyond avoiding myocardial infarction or stroke to preserving cognition, mobility, muscle strength, independence, and functional capacity. Cardiovascular disease, cognitive decline, and frailty share several important upstream determinants, including hypertension, diabetes, dyslipidemia, obesity, smoking, sedentary behavior, poor dietary quality, vascular dysfunction, chronic inflammation, and loss of skeletal-muscle reserve [3-6]. Frailty is particularly relevant because it reflects declining physiological resilience and can substantially modify the risks and benefits of cardiovascular interventions [1,7,8]. Similarly, cognitive impairment may influence medication adherence, informed decision-making, rehabilitation participation, and post-discharge recovery [1]. Cardiovascular care in older adults must therefore move beyond a disease-centered model toward a function-centered approach in which survival, cognition, mobility, independence, and quality of life are considered alongside conventional cardiovascular outcomes [1,6-8]. Why This Matters for Pakistan The biological-aging framework assumes particular importance in Pakistan because cardiometabolic risk factors frequently emerge long before patients enter specialist cardiovascular care. The Pakistan STEPS survey demonstrated a substantial burden of modifiable risk factors: 96.5% of adults consumed fewer than five servings of fruits and vegetables per day, 41.5% had low physical activity, 26.3% were overweight, 14.9% were obese, while stage I and stage II hypertension affected 37% and 15.9%, respectively [9]. These findings indicate that adverse cardiovascular and biological-aging trajectories may begin decades before overt cardiovascular disease becomes clinically apparent. Pakistan is also experiencing a rapid nutrition and lifestyle transition. Traditional dietary patterns increasingly coexist with greater consumption of commercially prepared and energy-dense foods, refined carbohydrates, fats, salt, and added sugars, particularly in urban populations [10]. This transition is occurring alongside reduced habitual physical activity and changing occupational and urban lifestyles. Such exposures are not merely conventional cardiovascular risk factors; accumulated over decades, they may contribute to vascular injury, metabolic dysfunction, inflammation, loss of physiological reserve, and ultimately accelerated biological aging [2-5]. This is where Pakistan differs importantly from many high-income healthcare settings. While geriatric cardiology increasingly incorporates frailty assessment, rehabilitation, cognitive evaluation, exercise, and shared decision-making, Pakistan must simultaneously address more fundamental barriers to healthy aging. These include delayed detection of hypertension and diabetes, fragmented preventive care, out-of-pocket healthcare expenditure, limited availability of cardiac rehabilitation, and minimal routine assessment of cognition and frailty. Consequently, cardiovascular disease may become clinically evident only after considerable physiological and functional reserve has already been lost. From Cardiovascular Prevention to Preservation of Biological Reserve The implications for prevention are substantial. Blood-pressure control, diabetes prevention, smoking cessation, regular physical activity, healthier dietary patterns, and maintenance of healthy body weight should not be viewed solely as strategies for reducing myocardial infarction and stroke. They should also be understood as interventions that may help preserve vascular, cognitive, metabolic, and functional reserve across the life course [4,5,11]. The INTERHEART study demonstrated the major contribution of modifiable risk factors to myocardial infarction across diverse populations [4], while the PURE study reinforced the importance of modifiable metabolic and behavioral factors for cardiovascular disease and mortality across countries at different income levels [5]. These findings are highly relevant to Pakistan: preventing cardiovascular disease earlier in life may also contribute to healthier aging later in life. For clinicians, implementation of this concept does not require sophisticated biomarkers or expensive biological-age testing. A practical approach could begin with brief assessment of frailty, cognition, mobility, nutrition, medication burden, and social support alongside conventional cardiovascular evaluation [1,7,8]. Simple measures such as gait speed, chair-rise performance, or validated frailty scales may provide clinically meaningful information about physiological reserve. Older adults admitted with acute coronary syndrome, heart failure, valvular heart disease, or arrhythmias should therefore be assessed not only according to ejection fraction, angiographic anatomy, and traditional risk scores, but also according to whether they can walk independently, understand and adhere to treatment, tolerate rehabilitation, manage polypharmacy, and recover function after discharge [1,7,8]. These dimensions may profoundly influence whether technically successful cardiovascular treatment translates into meaningful patient-centered recovery. The same principle extends beyond hospitals. Population-level interventions addressing hypertension, unhealthy diet, physical inactivity, obesity, and other major modifiable risk factors can influence the health trajectory long before biological reserve is depleted [11]. In a country with a large population exposed to cardiometabolic risks, preservation of healthy aging should therefore become part of cardiovascular prevention rather than being considered exclusively a geriatric concern. A Broader Definition of Cardiovascular Success The major contribution of the ACC Scientific Statement is its ability to connect cardiology with geroscience, cognition, frailty, and functional health [1]. It challenges cardiovascular medicine to look beyond procedural success and short-term event reduction toward outcomes that matter deeply to older adults: preserved cognition, mobility, independence, functional recovery, and quality of life. For Pakistan, this perspective has particular urgency. If health trajectories influence biological age, then hypertension, diabetes, poor diet, physical inactivity, rapid lifestyle transition, and gaps in preventive healthcare are not simply background public-health problems; they are determinants of how rapidly cardiovascular and functional reserve may decline. The next decade of cardiovascular prevention in Pakistan should therefore broaden its objective from preventing cardiovascular events to preserving biological and functional reserve across the life course. This requires earlier risk-factor detection, stronger primary prevention, greater access to rehabilitation, and routine consideration of frailty and cognition in older cardiovascular patients. Ultimately, the success of cardiovascular care should be judged not only by how many years are added to life, but also by how much cognitive, physical, and functional health is preserved within those years. 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