INTRODUCTION: Healthcare-associated infections (HAIs) and occupational exposures remain significant challenges in low- and middle-income countries where infection prevention and control (IPC) resources may be limited. The World Health Organization (WHO) emphasizes ongoing education and training as core components of effective IPC programs. This quality improvement project aimed to assess baseline IPC practices and evaluate the impact of a structured training intervention at a tertiary cardiac care center in Karachi, Pakistan. METHODS A pre-post intervention design was employed over 12 months from 1st July 2025–30th June 2026. The Infection Prevention and Biosafety Assessment Initiative (IPBAI) tool, comprising ten domains aligned with WHO IPC core components, was used to conduct a baseline gap analysis across nine clinical departments from 1st -15th July 2025. A comprehensive training module was developed and delivered in two cycles (1st -11th August 2025 and 13th -17th April 2026), reaching 607 healthcare workers. A post-intervention audit was conducted from 15th -30th June 2026, using the same tool. The primary outcome was change in the general indicator score from baseline to post-intervention. RESULTS The baseline gap analysis revealed a general indicator score of 72.5%, with substantial deficiencies in staff knowledge and practices across multiple domains, including standard and transmission-based precautions (20%), environmental cleaning (0%), spill response (20%), and antimicrobial stewardship (20%). Following the two-cycle training intervention, the post-intervention audit demonstrated marked improvement, with the general indicator rising to 94%. All ten IPC knowledge and practice domains achieved perfect scores of 100%. A total of 607 healthcare workers (n = 391 in Cycle 1 and n = 216 in Cycle 2) received structured IPC training. CONCLUSION Structured, multimodal training interventions based on comprehensive gap analysis can significantly improve IPC and biosafety practices. The IPBAI framework provides an effective, reproducible approach for assessing IPC gaps, implementing targeted education, and monitoring improvement in resource-constrained healthcare environments.

Background Pakistan, currently the fifth-largest country by population globally, has experienced a population increase of over 100% since 1990. It is facing an escalating challenge from cardiovascular diseases (CVD). The Global Burden of Disease (GBD) 2019 study provides an in-depth evaluation of Pakistan's health situation since 1990, offering essential insights into the nation's overall health conditions. Methods The data were obtained from the Global Burden of Disease Study 2019, which provides records for global, regional, and national burden of diseases. Specifically, data regarding CVD and its subtypes, morbidity, and mortality in Pakistan and globally from 1990 to 2019 were used for comparison. Data on the number of deaths, disability-adjusted life years (DALYs), age-standardized mortality rates (ASMRs), and age-standardized DALY rates (ASDRs), including their 95% uncertainty intervals (UIs) per 100,000 individuals, were analyzed. The changes over time from 1990 to 2019 were analyzed using the estimated annual percentage change (EAPC) and the respective 95% confidence interval (95% CI). Results From 1990 to 2019, the yearly count of deaths caused by CVD in Pakistan almost doubled, rising from 172,526 (95% UI, 147,996 to 197,521) to 341,108 (95% UI, 291,723 to 405,509). The ASMR for CVD remained relatively unchanged, moving from 329.39 (95% UI, 279.95 to 381.52) in 1990 to 357.88 (95% UI, 307.76 to 423.57) in 2019, with an EAPC of 0.09% (95% UI -0.09% to 0.31%), despite a global decline. The ASMR for males was stable, with a figure of 327.96 (95% UI, 276.88 to 387.59) in 1990 increasing to 376.84 (95% UI, 295.07 to 472.46) in 2019; likewise, the ASMR for females saw little change, going from 331.47 (95% UI, 261.88 to 416.47) in 1990 to 337.34 (95% UI, 280 to 420.44) in 2019. An inverted U-shaped trend was observed for both overall and sex-specific CVD ASMR and ASDR in Pakistan. On a global scale, a reduction in ASMR was noted for both males (EAPC, -0.3%; 95% CI, -0.35 to -0.25) and females (EAPC, -0.35%; 95% CI, -0.4 to -0.3). Ischemic heart disease continued to be the primary contributor to the burden of CVD, followed by ischemic stroke. The trend in ASDR mirrored that of ASMR for both genders in Pakistan. Conclusion Between 1990 and 2019, the overall CVD ASMR and ASDR exhibited an inverted U-shaped trend, remaining stable in Pakistan while decreasing globally. In the 1990s, Pakistan's CVD burden was more in line with the global burden; however, by the 2010s, it had surpassed the global CVD burden. To effectively tackle the CVD burden, policymakers need to prioritize the allocation of resources toward healthcare across various sectors. This initiative demands collaboration from all parties involved in the healthcare field, including policymakers.

Therapeutic Area ASCVD/CVD Risk Factors Background Lipoprotein(a) [Lp(a)] is an independent and genetically determined cardiovascular risk factor, with elevated levels associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD) and calcific aortic valve disease. South Asians have been shown to exhibit higher Lp(a) levels compared to other ethnic groups, yet limited nationally representative data exist on these populations. This study aims to evaluate the prevalence and distribution of Lp(a) across age and gender in a diverse Pakistani cohort, with risk stratification based on established Lp(a) cutoffs. Methods The PAKistan Study of prEmature coronary atHerosclerosis in young AdulTs (PAK-SEHAT) is an ongoing prospective study recruiting individuals from 08 centers across all four provinces of Pakistan. This analysis includes 2,000 participants aged 35–65 years. Lp(a) mass levels were measured by immunoturbidometric assays in both centers and expressed as mg/dL. Lp(a) concentrations were categorized into low risk (<30 mg/dL), intermediate risk (30–49 mg/dL), high risk (50–125 mg/dL), and very high risk (>125 mg/dL) and assessed across the total population as well as stratified by gender and median age groups. Results Among 2,000 participants with a mean age of 48.9 years, of whom 50% were female. The mean±SD Lp(a) levels were 27.0±29.2 mg/dL and median (interquartile range) levels were 16.5 (7.9-34.5) mg/dL, with range 0.04 to 226.0 mg/dL. Lp(a) levels at 75%, 80%, 90%, 95%, 99%, percentiles were >34.5, >41.4, >67.4, >86.5 and >141.5 mg/dL, respectively. Females had higher mean (SD) (29.1 [30.5] versus 24.8 [27.6]; P<0.0001) and median (interquartile range) (17.6 [8.7-36.7] versus 15.0 [7.2-32.8]; P<0.0001) Lp(a) than males. Spearman correlations suggested weak correlation between Lp(a) and, total cholesterol, LDL HDL and hs-CRP (r=0.105, r=0.132, r=0.09, r=0.027). Overall, 15% had Lp(a) levels>50 mg/dl (men: 12%, women: 18%). Conclusions This is the first large nationally representative study assessing the prevalence and distribution of Lp(a) in the Pakistani population. A substantial proportion of individuals were in the high-risk category, with approximately 15% having Lp(a) >50 mg/dl. Future studies should assess the impact of elevated Lp(a) on ASCVD outcomes and the role of emerging therapeutic interventions in this population.

Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of aortic stenosis, yet the majority of TAVR devices are optimized for Caucasian and Latin American aortic root anatomies. Unfortunately, data specific to the South Asian (SA) population is limited. This study sought to evaluate and compare aortic root dimensions in Pakistani patients undergoing TAVR with those of other racial groups. This study included consecutive patients undergoing TAVR workup at 2 tertiary care centers in Karachi, Pakistan. A comprehensive assessment of aortic root anatomy and dimensions was performed via cardiac computed tomography angiography. Data for 90 patients from a Japanese cohort and 181 patients from a European cohort were obtained from the published literature. In a sample of 494 patients, 58.1% (287) were male, and the mean age was 71.2 ± 9.7 years. The mean annular area was 427.33 ± 122.49 mm 2 , and the mean perimeter was 73.96 ± 10.17 mm. In comparison, the sinus of Valsalva (SOV) was <28 mm in 22.8% (113) versus 66.7% (60) versus 14% (17); left main height was <10.7 mm in 18.7% (90) versus 13.3% (12) versus 3.9% (7); and right coronary artery height was <12.7 mm in 14% (69) versus 7.8% (7) versus 2.2% (4) among the Pakistani, Japanese, and European cohorts, respectively. The Pakistani population exhibited a higher incidence of smaller SOV dimensions compared to the European cohort and a higher incidence of shorter coronary artery heights. These findings highlight the need for tailored TAVR device designs and procedural strategies to accommodate the unique anatomical characteristics of the SA population, ensuring optimal outcomes in this demographic.

Therapeutic Area ASCVD/CVD Risk Factors Background Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide, with South Asians, including Pakistanis, disproportionately affected by an earlier onset and more severe forms of disease. Traditional cardiovascular risk factors (CVRFs), play a significant role in CVD initiation progression, yet limited nationally representative data exist on their distribution across different age groups and genders in Pakistan. This study aims to evaluate the prevalence and distribution of traditional CVRFs in a diverse Pakistani cohort to better understand demographic disparities and inform targeted prevention strategies. Methods The PAKistan Study of prEmature coronary atHerosclerosis in young AdulTs (PAK-SEHAT) is an ongoing prospective study recruiting participants from 08 centers across all four provinces of Pakistan. This analysis includes 2,004 individuals aged 35–60 years. Data on CVRF’s were collected using standardized clinical assessments, laboratory measurements, and validated questionnaires. Prevalence rates were stratified across median age and gender. Results Among 2,004 participants (50% male, 50% female, median age: 49), the overall prevalence of major CVRFs was 32.9% for hypertension, 21.9% for diabetes, 57.8% for dyslipidemia, 10.8% for smoking, 32.4% for FH premature CHD and 37.6% for obesity. Hypertension and diabetes were significantly more prevalent in older age groups, with 41.3% of individuals aged >50 years having hypertension compared to younger individuals (p <0.001). Dyslipidemia (High LDL and low HDL) showed an increasing trend with age, while obesity was more prevalent in younger age groups, particularly among women. Smoking was predominantly observed in men (19.2%) compared to women (2.6%). Conclusions This is the first large nationally representative study assessing the distribution of traditional CVRF’s in Pakistan, highlighting significant variations across age and gender. These findings emphasize the urgent need for age- and gender-specific preventive strategies tailored to the unique risk profile of the Pakistani population to mitigate the growing burden of CVD.

BACKGROUND:Since 2012, our institute has contributed data to the National Cardiovascular Data Registry's CathPCI and Chest Pain-MI registries using manual forms and semidigital tools. PROJECT RATIONALE:Manual data entry across 4 registries by 3 research assistants led to workflow delays, duplication, and quality gaps. A centralized, electronic health record (EHR)-integrated solution was needed to improve accuracy, reduce redundancy, and streamline compliance reporting. PROJECT SUMMARY:We developed and launched Cardiopulse.pk, a fully paperless digital registry integrated with the hospital's EHR. The platform unified CathPCI and Chest Pain-MI data collection, enabled direct role-based entry, automated patient data transfer, and included built-in validation and skipping logic. It eliminated manual duplication, reduced research assistant workload by 67%, and improved data accuracy (from 60% to 95%) and completeness (from 40% to 100%). Historical data from 2012 to 2024 were successfully migrated. TAKE-HOME MESSAGE:This project shows that EHR-integrated digital registries can significantly enhance data quality, efficiency, and clinical ownership, and the outcomes can serve as a scalable model for other institutions.

Therapeutic Area ASCVD/CVD Risk Factors Background Dyslipidemia is a key risk factor for cardiovascular disease (CVD), with South Asians exhibiting a distinct lipid profile characterized by low HDL cholesterol (HDL-C), elevated triglycerides (TG), and increased LDL cholesterol (LDL-C). However, nationally representative data on lipid distributions across age and gender in the Pakistani population remain limited. This study aims to evaluate the prevalence and distribution of lipid parameters in a Pakistani cohort and identify demographic variations that may inform targeted lipid-lowering interventions. Methods The Pakistan Study of premature coronary at Herosclerosis in Young Adults (PAK-SEHAT) is an ongoing prospective study recruiting individuals from 08 centers across all four provinces of Pakistan. This analysis includes 2,004 participants aged 35–65 years. Fasting lipid profiles, including LDL-C, TG, and HDL-C, were measured using standardized laboratory assays. Lipid parameters were analyzed across age groups (≤49 years, >49 years) and gender. Results Among 2,004 participants with a mean age of 48.9 years, of whom 50% were female, the mean lipid levels were LDL-C: 127.5 mg/dL, TG: 217.9 mg/dL, HDL-C: 40.6 mg/dL. The prevalence of dyslipidemia was 47.4% for high LDL-C (≥130 mg/dL), 62.9% for high TG (≥150 mg/dL), and 68.2% for low HDL-C (<40 mg/dL in men, <50 mg/dL in women). LDL-C distribution showed 21.9% of the population had optimal levels (<100 mg/dL), while 4.9% had very high LDL-C (≥190 mg/dL). LDL-C levels increased significantly with age. Among men, 60.9% had low HDL-C vs 75.5% in women. Triglyceride abnormalities were highly prevalent, with 20.7% borderline high (150–199 mg/dL), 37.6% high (200–499 mg/dL), and 4.6% very high (≥500 mg/dL). Multivariable regression analysis identified central obesity, diabetes, metabolic syndrome, and physical inactivity as strong predictors of low HDL-C and high TG, while hypertension and male gender were associated with higher LDL-C. Conclusions This is the first large nationally representative study evaluating the distribution of lipid parameters in the Pakistani population, revealing significant variations across age and gender. A high prevalence of low HDL-C and elevated TG was observed, particularly among younger individuals and women, while LDL-C burden increased with age. These findings highlight the urgent need for targeted dyslipidemia management strategies to mitigate the growing burden of atherogenic lipid profiles in this high-risk South Asian population

Background: Intraplaque delivery of contrast has been utilized during percutaneous coronary interventions (PCI) of chronic total occlusions (CTO) to delineate anatomy and to facilitate wire crossing. Its utility as a tool to accomplish primary crossing of CTOs has not been described or validated. Aims: We describe a new technique leveraging the diagnostic and therapeutic roles of intraplaque contrast injection to accomplish primary crossing of CTOs: HydroDynamic contrast Recanalization (HDR). Methods: HDR is an antegrade crossing method for coronary CTOs based on the synergistic use of contrast microinjections and polymer jacketed wires. We present a retrospective, first-in-man, case series utilizing HDR for CTO PCI in patients with favorable CTO anatomy (visible proximal segment and identifiable distal target). The primary outcome was procedural success. The secondary outcome was any procedural complications. Results: A total of 43 patients with 45 CTOs underwent CTO PCI with HDR. Mean patient age was 64.3 +/- 11 years. The mean Japanese CTO and PROGRESS CTO scores were 2.3 +/- 0.7 and 1.8 +/- 0.7, respectively. CTO complexity was high, with an ambiguous or blunt cap in 34 occlusions (76%); lesion length >= 20 mm in 27 occlusions (60%); and moderate/heavy calcification in 36 occlusions (80%). Procedural success using HDR was 100%. There were no complications. Conclusions: This study shows the utility of HDR in CTO PCI. HDR appears to be a safe and promising new contrast-based primary crossing technique in selected patients. This strategy warrants further evaluation in larger prospective studies.

Background:Out-of-hospital cardiac arrest (OHCA) is a major cause of morbidity and mortality globally, with survival outcomes remaining poor particularly in many low- and middle-income countries. We aimed to establish a pilot OHCA registry in Karachi, Pakistan to provide insights into OHCA patient demographics, pre-hospital and in-hospital care, and outcomes. Methods:A multicenter longitudinal study was conducted from August 2015-October 2019 across 11 Karachi hospitals, using a standardized Utstein-based survey form. Data was retrospectively obtained from medical records, patients, and next-of-kin interviews at hospitals with accessible medical records, while hospitals without medical records system used on-site data collectors. Demographics, arrest characteristics, prehospital events, and survival outcomes were collected. Survivors underwent follow-up at 1 month, 6 months, 1 year, and 5 years. Results:In total, 1068 OHCA patients were included. Mean age was 55 years, 61.1 % (n = 653) male. Witnessed arrests accounted for 94.9 % of the cases (n = 1013), whereas 89.4 % of the cases (n = 955) were transported via non-EMS. Bystander CPR was performed in 10.3 % (n = 110) cases whereas pre-hospital defibrillation performed in 0.4 % (n = 4). In-hospital defibrillation was performed in 9.9 % (n = 106) cases despite < 5 % shockable rhythms. Overall survival to discharge was 0.75 % (n = 8). Of these 8 patients, 7 patients survived to 1-year and 2 to 5-years. Neurological outcomes correlated with long-term survival. Conclusion:OHCA survival rates are extremely low, necessitating public awareness interventions like CPR training, developing robust pre-hospital systems, and improving in-hospital emergency care through standardized training programs. This pilot registry lays the foundation for implementing interventions to improve survival and emergency medical infrastructure.

There is dearth of literature addressing early outcomes of acute coronary syndrome (ACS) among young patients, particularly South Asians descent who are predisposed to premature coronary artery disease (CAD). Therefore, we compared presentation, management, and early outcomes of young vs. old ACS patients and explored predictors of in-hospital mortality. We extracted data of 23,560 ACS patients who presented at Tabba Heart Institute, Karachi, Pakistan, from July 2012-June 2020, from the Chest pain-MI-Registry™. We categorized data into young ≤ 45 and old ACS patients > 45 years. Chi-sq/Fischer exact tests were used to assess the difference between presentation, disease management, and in-hospital mortality between both groups. Logistic regression was used to determine odds ratio along with 95

Objectives: To date, no optimal way of organizing and delivering care to hypertensive patients at the primary care level has been identified, due to which a significant number of patients fail to meet the treatment goals. The current study aimed to observe hypertension educational intervention's effect on general physicians (GPs) to indirectly improve blood pressure control and patient outcomes. Methodology: In this randomized control trial, GPs were divided into 2 groups, and both groups were asked to fill hypertension awareness questionnaire at baseline and after randomization. GPs of the group I received (1 day) face-to-face education with structured educational material on hypertension management strategies. GPs of group II received the print version of educational material (structured educational material) on strategies for structured hypertension management. Both GPs recruited 10 (5 newly diagnosed + 5 already diagnosed patients) from the study site. The patient was asked to fill hypertension awareness questionnaire at baseline and share a 12-hour blood pressure measurement. GPs and patients were reassessed after 3 months of intervention. Results: The Primary endpoint was achieved successfully, i.e., significant change between Pre & Post change blood pressure control. Both the Secondary endpoints were met with a notable change in practice specific to hypertension management as well as knowledge enhancement among GPs and patients regarding hypertension management. Conclusion: The overall effect of hypertension educational intervention for general physicians has indirectly improved blood pressure control and patient outcomes. The results of this study provide a foundation for developing a hypertension educational program targeted at general physicians.

This narrative review seeks to elucidate clinical and social factors influencing cardiovascular health, explore the challenges and potential solutions for enhancing cardiovascular health, and identify areas where further research is needed to better understand cardiovascular issues in native and American Pakistani populations. The prevalence of cardiometabolic disease is high not only in Pakistan but also among its global diaspora. This situation is further complicated by the inadequacy of current cardiovascular risk assessment tools, which often fall short of accurately gauging the risk among Pakistani individuals, underscoring the urgent need for more tailored and effective assessment methodologies. Moreover, social determinants play a crucial role in shaping cardiovascular health. The burden of cardiovascular disease and upstream risk factors is high among American Pakistani individuals. Future research is needed to better understand the heightened risk of cardiovascular disease among Pakistani individuals.

Therapeutic Area: ASCVD/CVD Risk Factors Background: There is a scarcity of literature exploring early outcomes of young acute-coronary-syndrome patients, predominantly in South Asians, who are considered to be at most risk of developing premature coronary artery disease. Therefore, we compared presentation, management, and early outcomes of young vs. old ACS patients and explored predictors of in-hospital mortality. Methods: We extracted data of 23,560 ACS patients presented at Tabba Heart Institute, Karachi, Pakistan, from July 2012-June 2020, from the Chest pain-MI Registry™. Young patients: ≤45 years. Chi-sq/Fischer exact tests assessed the difference between variables in younger vs. older patients. Logistic regression was used to determine predictors of early mortality, and odds ratios along with 95% confidence intervals were reported. Results: The mean age was 59.0±11.4 years, women: 23.5%, and younger patients: 12.3%. Dyslipidemia (34.5% vs. 22.4%), diabetes (52.1% vs. 27.4%) and hypertension (68.3% vs. 42.9%) were higher in older adults. In contrast, Family history of premature coronary artery disease (32.7% vs. 18.1%) and smokeless-tobacco (8.4% vs. 6.5%) was higher in young adults. Younger adults were more likely to present with STEMI (45% vs. 33.2%) and be asymptomatic on presentation (40.8% vs. 36.1%). Median symptom-to-door-time was higher in younger patients (760(192, 3140) vs. 635(186,2735) minutes). Coronary angiography and CABG were higher in older patients; however, PCI was higher in young adults. The use of all medications in first 24 hours except IV anticoagulant and angiotensin receptor blockers was higher in younger adults. In-hospital mortality (4.3% vs. 1.7%) and complications including cardiac arrest (1.9% vs. 0.7%), cardiogenic shock (1.9% vs. 0.9%) and heart failure (1% vs. 0.6%) were more common in older patients. After adjusting for risk factors, older age (2.4, 1.5-3.7) was a significant predictor of early mortality. Other predictors included: STEMI (OR:3.2, 95% CI:1.9-5.5), women (1.4, 1,1-1.8), Killip III/IV (3, 2.4-3.8), cardiac arrest (3.2, 2.2-4.5) and heart failure (1.8, 1.4-2.3) at presentation, Left ventricular ejection fraction (0.9, 0.93-0.95) and PCI (1.3, 1.1-1.7) and CABG (3, 2.3-3.9) at index hospitalization. Conclusion: Younger patients presented differently from their older counterparts as they were likely to be asymptomatic and have STEMI. They had favorable clinical outcomes, which might be explained by the aggressive treatment.

Objectives: In Pakistan, cardiovascular risk factors for acute myocardial infarction are increasing. There are few studies available on atherosclerotic risk factors in young patients and its outcome The purpose of this study was to compare pattern of traditional CVD risk factors, hospital mortality and major adverse cardiac events at discharge in young versus old patients (≤45years and above 45 years age respectively) admitted with STEMI and undergoing primary PCI. Methodology: This retrospective cohort study was conducted on consecutive patients presenting with STEMI between June 2013 and June 2018 in a single centre cardiac only tertiary care setup. Institute’s registry is fashioned along and is affiliated with US NCDR. Patients with cardiac arrest or cardiogenic shock at arrival were excluded. MACE was defined as post PCI cardiac arrest or cardiogenic shock, heart failure, major bleed or hospital death. Models were built using stepwise forward logistic regression method. Results: Total of 5343 patients were admitted with STEMI during study period, after exclusion data of 1642 patients were analyzed. Among young patients, the frequency of the male gender, any tobacco use and family history of premature coronary artery disease were significantly higher (all p values < 0.001). While in older STEMI patients frequency of heart failure, hypertension, prior myocardial infarction, diabetes mellitus ,abnormal creatinine clearance (<90 mL/min/1.73 m²) , multi-vessel coronary disease, advanced Killip class and higher body mass index was more prevalent (all P<0.001). Among young patients advanced Killip class and femoral access site(all P values <0.001), diabetes mellitus (p=0.03), abnormal creatinine clearance(p=0.04),and left ventricular ejection fraction less than 40%(p=0.01), were more significant in-hospital mortality predictor whereas advanced Killip class, Left ventricular ejection fraction less than 40% male gender(p=0.04), diabetes mellitus(p=0.001),femoral access site(p=0.001), and Left ventricular ejection fraction less than 40% were more significant MACE predictors (all P<0.001). Conclusion: There were no significant difference in hospital mortality and MACE among young versus old STEMI patients when adjusted for diabetes mellitus, abnormal creatinine clearance (<90 mL/min/1.73 m²), multi-vessel coronary disease, advanced Killip class. Tobacco use is the main modifiable risk factors for young patients with STEMI. Surprisingly, being a woman and having a positive family history with premature coronary artery disease were protective.