Objectives: To elucidate the involved culprit arteries and proportion of spontaneous arterial recanalization (SAR) in acute lateral wall myocardial infarction (ALWMI) patients in Pakistan.Methodology: This cross-sectional study was conducted in the outpatient department (OPD) of a tertiary care cardiac center from February 2019 to July 2019. Patients meeting selection criteria of ALWMI were included. Key angiographic outcomes were recorded for each patient. Proportion of SAR in terms of involved culprit arteries was assessed.Results: One hundred fifty two (152) patients were included, out of which 81% (124) were males. Mean age was 54.73 ± 11.03 years. Most (46.4%) of the study patients presented with single vessel disease. Overall, 89 (59%) patients showed SAR with settled ECG changes. Of them 73 (66%), 8 (33%) and 8 (47%) patients had diagonal artery involvement, 1st obtuse marginal artery involvement and ramus intermedius artery involvement respectively. Statistical significance (p=0.006) is observed for relationship of involved culprit arteries and SAR in ALWMI patients.Conclusion: This cross-sectional study reports the proportion of arterial recanalization in terms of involved culprit arteries. Diagonal was the culprit artery (~ 73%) in most patients presented with ALWMI. SAR proportion is also highest in patients with diagonal artery involvement. This tendency of SAR was more in single vessel diseases patients compared to double vessel and triple vessel diseases patients.

Objective This study aimed to assess the duration of pre-hospital delay among ST-Segment Elevation Myocardial Infarction (STEMI) patients and its contributing factors. Methodology A cross-sectional study was conducted at Rural Satellite Center in Larkana, Pakistan from May to September 2020. A total of 240 STEMI patients who underwent primary percutaneous coronary intervention (P-PCI) were included. The patients' demographic characteristics, index event characteristics, mode of transportation, misinterpretations, misdiagnoses, and financial problems were recorded. Data were analyzed using SPSS version 22.0 (IBM Corp., Armonk, NY, USA). Results The observed pre-hospital time was 120 minutes; 229 (median; interquartile range [IQR]). It was found that 33.3% of patients arrived within one hour of the symptom onset, while 20.4% of patients delayed hospital arrival for more than six hours. The delay rate was highest among patients aged 41 to 65 years. Moreover, delayed admissions were more common among females as compared to males (p=0.008). Among the causes of delay in hospital arrival were misinterpretation, misdiagnosis, and transportation and financial issues. Of these, misdiagnosis significantly influenced the delay rate, i.e., more than 50% of the misdiagnosed patients arrived hospital after six hours of symptom onset (p<0.05). Conclusion The P-PCI rural satellite center had a positive impact as the observed pre-hospital delay rate was considerably less as compared to that reported in the existing literature. Moreover, the confounding factors were misdiagnosis and misinterpretations. We need to develop the concept of immediate appropriate help-seeking among patients.

Objective: Acute pulmonary edema (APE) is a common problem presenting in emergency department of cardiology units. For decades, the mainstay of treatment in APE has been loop diuretics; mainly furosemide. Studies regarding mortality benefits of diuretics in APE patient have not been conducted in our population, where other drugs of heart failure are not frequently available. Therefore, results of our study may provide justification for continued use of diuretics as mainstay treatment of APE. Aim of this prospective study was undertaken to determine the relationship between dose of furosemide and mortality. Methodology: This prospective study was conducted at department of cardiology, SMBBMU, Larkana from June 2017 to December 2017. Patients of either gender, aged between 18 to 75 years presenting with diagnosis of APE were included in the study. Patients were followed up till time of discharge or death. Outcome variable i-e mortality was noted and recorded. Results: A total of 402 patients were included in this study out of which 234 (58.2%) were males. In-hospital mortality was 17.9% (77). Total amount of diuretics used was significantly lesser among the patients who died (209.28 ± 134.15 ml vs. 295.18 ± 151.43 ml; p-value <0.001). Patients who received less than 300mg/day diuretics had increased mortality as compared to those who received more than 300 mg/day (59 (20.3%) vs. 13 (11.7%); p-valve 0.045). Conclusion: Patients who received less diuretic had more mortality than those who received more diuretic.

Background and Objective: Depression and anxiety are very common in patients with cardiac diseases. Percutaneous coronary intervention (PCI) has not only decreased mortality but angina, heart failure and recurrent hospitalization all are improved. Therefore, anxiety and depression associated with fibrinolytic therapy in acute coronary syndrome (ACS) are expected to be decreased in the patient undergoing PCI. Therefore, the aim of this study was to determine prevalence of depression and anxiety in patients undergoing percutaneous coronary intervention for acute coronary syndrome. Methods: This study was conducted at Larkana Satellite Center of National Institute of Cardiovascular Diseases (NICVD), Pakistan from August 2018 to December 2018. Patients who underwent cardiac intervention within one month were enrolled in this study. Patients were interviewed regarding their basic demographics, indication for intervention and procedure details. Symptoms of anxiety were assessed using the translation of inventory of SAS (Zung's Self-Rating Anxiety Scale). Patients were interviewed for depression by using Becks depression inventory (BDI). Results: A total of 153 patients were included in this study out of which 118(77.1%) were males and 35(22.5%) were females. All were married except one. Diabetes mellitus (DM) was present in 61(39.9%), hypertension (HTN) in 69(45.15%), obesity in 15(9.8%), and 40 (26.1%) were smokers. Depression was present in 16 (10.5%) patients and anxiety was present in 12(7.5%) of patients. On analysis of the association of various factor with depression; non-diabetics, housewives, laborers and uneducated were found to be more depressed. While those who smoke or earn more than 50 thousand were found less likely to be depressed. Conclusion: Both depression and anxiety were present in only 10.5% and 7.5% of the patients after percutaneous coronary intervention for acute coronary syndrome.

Objectives: To determine the frequency of dual antiplatelet adherence at six months after primary PCI performed at rural satellite center. Methodology: This was a descriptive study conducted at Rural Satellite Center (Larkana) of the National Institute of Cardiovascular Disease, Pakistan from October 2017 to March 2018. Patients of either gender between the ages of 20-80 years who underwent primary Percutaneous Coronary Intervention (PCI) at least six months ago were included in this study. Compliance with antiplatelet therapy was assessed by interview at follow up. Patients were labeled as compliant if they took both aspirin and clopidogrel at the time of follow up at six months. Results: Of the total of 241 patients, 208 (86.3%) were male. The mean age of the patients was 53.37 ± 11.07 years. Hypertension was present in 170 (70.5%), 101 (41.9%) were diabetic, 104 (43.2%) were smokers and 18 (7.5%) were obese. The most common culprit artery was left anterior descending (LAD) artery, 149 (61,8%), followed by the right coronary artery (RCA) in 83 (34.4%) patients. Nearly 12.1% (31) patients had the three-vessel disease, whereas, 53.9% (130) patients had single-vessel involved. Compliance with antiplatelet therapy at six months was found to be 89.6%, 219 (90.9%) were compliant to aspirin while 218 (90.5%) were compliant to clopidogrel. Conclusion: In our population, a significant number of patients (10.4%) were not compliant with dual antiplatelet therapy after six months of primary PCI. The dual antiplatelet adherence, in our population, is lower than in developed countries. Therefore, efforts should be made to increase compliance. Keywords: ACS, Aspirin, clopidogrel, Dual antiplatelet, Myocardial infarction

Introduction Primary percutaneous coronary intervention (PPCI) is now a well-established treatment of acute ST-elevation myocardial infarction (STEMI). For the first time in Pakistan, various off-site satellite centers are established to perform PPCI 24-hours. Our population mainly resides in the rural area with low literacy rate and poor socioeconomic conditions. The majority of the patients who are presented in the satellite center had either never received any long-term treatment plan or were non-compliant to their medication. The objective of this study was to determine the outcome of patients at six months who underwent primary PCI at a rural satellite center of Sindh, Pakistan. Methods This study was conducted at Larkana satellite center of National Institute of Cardiovascular Diseases, Karachi. Patients who underwent PPCI for STEMI from October 2017 to March 2018 were enrolled in the study. In case of death of the patient, data were obtained from the attendant of the deceased. Patients, on follow-up visits, were interrogated for post-procedure symptoms. Results A total of 271 patients were enrolled in the study. The mean age ± standard deviation of patients was 54.84 ± 10.64 years. The most common culprit artery was left anterior descending (LAD) artery with 161 (59.4%) patients, followed by right coronary artery (RCA) with 98 (36.2%) patients. Only 41 (15%) patients had a three-vessel disease, while 141 (52%) patients had single-vessel disease. On follow-up, 70 (25.8%) patients complained of chest pain grade II, 20 (7.4%) complained of shortness of breath (SOB) grade II, 44 (16.2%) complained of vertigo, and 16 (5.9%) complained of nonspecific weakness. The mortality rate of 6.3% (17) was observed after six months of PPCI. The mortality rate was found to be lower for patients with LAD disease (p = 0.036) and higher among patients with RCA as the culprit artery (p = 0.045). The mortality rate was significantly associated with the number of diseased vessels and the type of stent deployed. Conclusion Primary PCI, at a rural satellite center, has an overall positive outcome. Steps should be taken to provide free medication along with encouragement towards compliance of dual antiplatelet medication. Furthermore, the facility for subsequent procedures should be provided at the same set-up.

Background & Objective: Due to increase in number of cardiac catheterization procedures safety concerns is an issue nowadays. Multiple diagnostic modalities use radiations, which also put a patient at higher cumulative radiation exposure. Therefore steps should be taken to minimize radiation exposure during cardiac catheterization. Hence determination of factors which prolong FT will result in better understanding of problem. This retrospective study was undertaken to determine factors responsible for prolong fluoroscopy time in patients undergoing coronary artery catheterization. Methods: This retrospective study was conducted at catheterization Laboratory National Institute of Cardiovascular Diseases, Karachi from June 2014 to June 2015. Patients of either gender, aged between 18 to 90 years undergoing cardiac catheterization procedures were included. Radiation exposure time was measured in terms of fluoroscopy time. Results: A total of 957 patients were included in this study out of which 731 were of diagnostic Coronary Angiograms (CA) and 226 were of Percutaneous Coronary Intervention (PCI). The mean age of the study participants was 54.12±10.89 years and majority 734(76.6%) were male. Mean fluoroscopy time (FT) in the patients subjected to PCI was 9.61±6.07 minutes while in cases for CA 4.17±4.13 minutes. FT for CA was observed significantly dependent on procedural access, operator’s experience, and LV angiogram. While FT for PCI was found dependent on number of stents deployed during the procedure. Conclusion: For invasive coronary angiographic procedures radial route increased fluoroscopy time. For percutaneous coronary intervention femoral and radial route fluoroscopy time were not significantly different.

Background: HRQL is important in improving the quality of patient care. However, there is a paucity of data from low-income and middle-income countries (LMIC). Differences in socio-demographics and socio-cultural contexts may influence HRQOL. Therefore, this research was designed with the aim to explore the HRQOL in patients after Percutaneous Coronary Intervention (PCI).Objective: The goal of the study was to evaluate the quality of life after six months of Percutaneous Coronary Intervention using HeartQol questionnaire at a tertiary care hospital in Pakistan.Method: This was a Cross-sectional, descriptive study. Patients between the ages of 20-60 years who underwent primary Percutaneous Coronary Intervention at least 6 months ago were inducted in the study. Coronary angiography was performed mostly through radial as preferred route. Data was collected using a structured questionnaire covering demographic characteristics, predisposing risk factors, procedural details, and quality of life. Heart related Quality of life was assessed using HeartQol questionnaire. Collected data was analyzed using SPSS v.21.Results: A total of 241 patients participated in the study. Mean age of the patients was 53.37±11.07 years. On analysis of quality of life at six months, the median (IQR) HeartQol score was 31 (37-23) with majority of the patients, 84.22% (203) fall under the excellent score (>20).Conclusion: It is of enormous prognostic importance that the quality of life of patient is assessed on a regular basis after PCI. Our study shows that the majority of patients had improved quality of life at six months of PCI. Majority of patients were not bothered by mild symptoms. Further investigation needs to be done to validate these results.

In complex coronary artery disease percutaneous coronary angioplasty (PCI) is increasingly employed. During the procedure of PCI to open the occluded vessels and to facilitate the balloon and stent deployment a number of different steerable coronary guide wires are used. However, the guide wires are not without hazards: these can perforate or dissect the vessel. Fracture and entrapment of the guide wires itself although uncommon but is also a serious complication. Management of fractured coronary guide wire depends upon the clinical situation of the patient and the position and length of the fractured remnant.We report two cases of broken coronary guide wire within the coronary tree during PCI. First case was during intervention on a chronic totally occluded artery (CTO) while 2nd case was during P-PCI. Both wires were retrieved, arteries were opened and stented in 1st case while only POBA was done successfully in 2 case.

Objective: To determine various reasons of medical noncompliance in heart failure patients.Study Design: Observational survey.Place and Duration of Study: National Institute of Cardiovascular Diseases, Karachi from January2010 to August 2010.Methodology: Study was conducted in all medical wards of NICVD. We included patients who werealready diagnosed heart failure and were on treatment. Patients were asked for reason ofnoncompliance. Data was analyzed using spss V-13.Results: Out of 267 patients 73 (27.3%) were compliant while 194 (72.7%) were noncompliant.Various reasons of non compliance were, inadequate prescription 20.2%, financial reasons 15.5%,15.5% of the patients doesn’t feel need of taking medication, miscommunication 15%, side affects13.5%, nonavailability of medication 11.4%, 7.3% other reasons and 1.1% medication werestopped due to other illness.Conclusion: Medical noncompliance has many reasons. Financial, social, and medical are the mainreasons.