BACKGROUND Lipid treatment practices and levels in post-acute myocardial infarction (AMI) patients, which are crucial for secondary prevention. AIM To evaluate the lipid treatment practices and lipid levels in post-myocardial infarction (MI) patients at a tertiary care hospital in Pakistan. METHODS In this cross-sectional study, we analyzed patients who had experienced their first AMI event in the past 3 years. We assessed fasting and non-fasting lipid profiles, reviewed statin therapy prescriptions, and examined patient compliance. The recommended dose was defined as rosuvastatin ≥ 20 mg or atorvastatin ≥ 40 mg, with target total cholesterol levels set at < 160 mg/dL and target low-density lipoprotein cholesterol (LDL-C) at < 55 mg/dL. RESULTS Among 195 patients, 71.3% were male, and the mean age was 57.1 ± 10.2 years. The median duration since AMI was 36 (interquartile range: 10-48) months and 60% were diagnosed with ST-segment elevation MI. Only 13.8% of patients were advised to undergo lipid profile testing after AMI, 88.7% of patients were on the recommended statin therapy, and 91.8% of patients were compliant with statin therapy. Only 11.5% had LDL-C within the target range and 71.7% had total cholesterol within the target range. Hospital admission in the past 12 months was reported by 14.4%, and the re-admission rate was significantly higher among non-compliant patients (37.5% vs 5.6%). Subsequent AMI event rate was also significantly higher among non-compliant patients (43.8% vs 11.7%). CONCLUSION Our study highlights that while most post-AMI patients received the recommended minimum statin therapy dose, the inadequate practice of lipid assessment may compromise therapy optimization and raise the risk of subsequent events.

Objectives: Despite widespread use of smokeless tobacco (ST) in Pakistan, a very limited empirical evidence have been reported regarding its impact on the coronary anatomy and obstructions. Therefore, this study was conducted to compare the coronary angiographic profile of smokeless tobacco (ST) users and smokers with non-tobacco users presented with acute myocardial infarction (AMI). Methodology: Consecutive patients with AMI were stratified in to four groups as tobacco non-users (G1), solo ST users (G2), both smoking and ST users (G3), and solo smokers (G4). Coronary angiographic findings regarding number of diseases vessels and infarct related artery were recorded. Results: Out of 326 patients, ST users were 28.2%(92), 6.4%(21) in conjunction with smoking and reaming 21.8%(71) without smoking. Females were 19.7%(14/71) of G2, 4.8%(1/21) of G3, 0% in G4. Young patients (≤ 40 years) were 3.4%(5/149) of G1, 9.9%(7/71) of G2, 14.1%(12/85) of G4, and 23.8%(5/21) of G3 cumulatively making 82.8%(24/29) of the young patients. Single vessel disease (SVD) and left anterior descending artery (LAD) were significantly higher among ST user as compared to non-users with distribution of 46.7% vs. 34.2% and 70.7% vs. 56.4% respectively. Conclusion: The distribution and localization of involved vessels among ST users with AMI are same as that of smokers with SCD and LAD as infarct artery as the common findings. Tendency of ST use is also high among female patients and Tobacco use in either form, smoking or smokeless, is alarmingly high (>80%) among young (≤40 years) patients with AMI.

Objectives: Peripheral arterial disease (PAD) is still underdiagnosed and undertreated diseases accounts for a considerable part of cardiovascular disease. Therefore, the objective of this study was to determine the pattern of vascular involvement in patients with lower extremity peripheral artery disease. Methodology: In this study we reviewed hospital record files and angiographic films of the patients’ undergone conventional peripheral angiography. Patterns of vascular involvement was assessed in terms of involved arterial segments, site (right, left, or both), size (%), and type of lesion (discrete, tubular, or diffused). Results: A total of 74 patients were included, out of which 60 (81.1%) patients were male. A majority, 85.1% (63), were diabetic, 78.4% (58) were hypertensive, 43.2% (32) were smokers, and 23% (17) had coronary artery disease. The most common involved location was superficial femoral (51.4%) followed by anterior tibial (45.9%), posterior tibial (45.9%), popliteal (21.6%), and peroneal (16.2%). Female patients had significantly higher rate of superficial femoral diseases as compare to the male patients with rate of 85.7% (12/14) vs. 43.3% (26/60); p=0.004 respectively. Conclusion: In conclusion, the most common risk factor for PAD was found to be diabetes and a significant number of patients were also found to have hypertension, and smoking. The most common involved segment was superficial femoral in our population followed by anterior tibial, posterior tibial, popliteal, and peroneal.

Objectives:Primary percutaneous coronary intervention (PCI) remains recommended reperfusion therapy for patients with acute ST-elevation myocardial infarction. This study aimed to evaluate the short-term major adverse cardiac events (MACE) and their determinants among patients who underwent primary PCI at a tertiary care cardiac center of Karachi, Pakistan. Methods:A cohort of patients who underwent primary PCI were followed for the MACE. Multivariable Cox-regression analysis was performed with backward conditional variable selection and hazard ratio (HR) along with 95% confidence interval (CI) were obtained. Results:A total of 1150 patients were included, of which follow-up was successful in 95.8% (1102) and median follow-up duration was 6.1 [6.9-5.1] months. MACE were observed in 210 (19.1%) patients with 14.2% (157) all-cause mortality, 5.4% (60) cardiac mortality, 0.7% (8) stroke, 3.6% (40) re-hospitalization due to heart failure, and 6.1% (67) myocardial infarction requiring revascularization. Independent predictors of short-term MACE were found to be admission glucose ≥200 mg/dL (1.66 [1.25-2.21]), serum creatinine ≥1.5 mg/dL (1.52 [1.02-2.27]), intubation (2.81 [1.98-4.00]), history of PCI (2.06 [1.45-2.93]), history of cerebrovascular accident (2.64 [1.34-5.2]), left ventricular end-diastolic pressure ≥20 mmHg (1.81 [1.3-2.51]), triple vessel diseases (1.43 [1.08-1.9]), culprit left main or proximal left anterior descending artery (1.77 [1.32-2.35]), pre-ballooning (2.14 [1.2-3.82]), and thrombus grade ≥4 (2.21 [1.51-3.24]). Conclusions:A significant number of individuals undergone primary PCI are still vulnerable to subsequent short-term MACE, hence, systematic follow-up and early risk stratification should be considered as an integral part of STEMI management protocol specially for patients with high-risk features as highlighted herein.

Background: Primary percutaneous coronary intervention (PCI) is a recommended management strategy for patients with de novo ST-segment elevation myocardial infarction (STEMI). Still, the efficacy of pri-mary PCI in-stent thrombosis (ST) induced STEMI is unclear. The aim was to assess the clinical charac-teristics and the in-hospital outcomes of patients undergoing primary PCI for STEMI caused by acute, sub-acute, or late ST.Methods: A sample of hundred consecutive patients who presented with STEMI due to ST were included in this study. The angiographic evidence of a flow-limiting thrombus or total vessel occlusion (throm-bolysis in myocardial infarction (TIMI) flow grade 0 to II) at the site of the previous stent implant was taken as ST. Primary PCI was performed, and all enrolled patients and in-hospital mortality were observed.Results: Male patients were 69, and the mean age was 58.9 +/- 7.78 years. ST was categorized as acute in 40 patients, sub-acute in 53, and late in the remaining seven patients. Killip class III/IV was observed in 45 patients. Dissection was observed in 25, under deployment in 74, and/or malposition in 24 patients. Thrombus aspiration was performed in 97, plain old balloon angioplasty in 76, and stenting in 22 pa-tients. Final TIMI III flow was achieved in 32 patients. During a mean hospital stay of 4.93 +/- 2.46 days, the mortality rate was 27%. Conclusion: In-hospital mortality after primary PCI was observed in more than 1/4th of the patients with STEMI due to ST undergoing primary PCI.(c) 2022 Published by Elsevier, a division of RELX India, Pvt. Ltd on behalf of Cardiological Society of India. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Background Accurate management of non-ST elevation myocardial infarction (NSTEMI) patients can be achieved by stratifying risks as early as possible on hospital admission. Previously, the Thrombolysis in Myocardial Infarction (TIMI) risk score has been validated and used on patients presenting with NSTEMI or unstable angina (UA) in developed countries. The aim of this study was to assess the validity of the TIMI risk score in patients presenting with NSTEMI in Pakistan. Methods This cross-sectional study was undertaken on 300 patients who were diagnosed with NSTEMI. Data were collected from medical records, the TIMI score was calculated, and 14-day outcome was recorded. The receiver operating characteristic (ROC) curve analysis was performed, and area under the curve (AUC) along with 95% confidence interval (CI) was reported. Univariate and multivariate logistic regression analysis was performed and odds ratio (OR) along with 95% CI was reported. Results This cross-sectional study was undertaken on 300 patients who were diagnosed with NSTEMI. Data were collected from medical records, the TIMI score was calculated, and 14-day outcome was recorded. Validity of TIMI score in predicting hospital mortality 14 days after the diagnosis of NSTEMI in a population in Pakistan was assessed by ROC curve and logistic regression analysis. The AUC of the TIMI score for predicting 14-day outcome was 0.788 [95% CI: 0.689-0.887], with optimal cutoff of ≥4 with sensitivity of 77.78%. On multivariate analysis, cardiac arrest at presentation and the TIMI risk score were found to be independent predictors of 14-day mortality with adjusted ORs of 136.49 [10.23-1821.27] and 2.67 [1.09-6.57], respectively. Conclusions The TIMI risk score is a useful and simple score for the stratification of patients with high risk of 14-day mortality with reasonably acceptable discriminating ability in patients with NSTEMI acute coronary syndrome.

Objectives: The main objective of the study was to evaluate the knowledge of patients for stents and post PCI pharmacotherapy. Methodology: A cross-sectional study was carried out on 102 consecutive selected patients with age ≥ 18 years who had undergone elective PCI. Various patient characteristics including demographics, previous history of cardiac problems, evaluation processes and overall knowledge were assessed using the survey questionnaire. With regards to evaluating levels of knowledge and awareness, the percentage for the number of correct answers about the dangers and advantages of elective PCI, clinical therapy for CAD, and bypass surgery was calculated. Results: A total of 102 patients were include, 78(76.5%) were male with mean age of study population was 53.93±11.0 years and majority 66(64.7%) were above 50 years of age. On analysis of demographics data it was observed that 74(72.5%) were educated. The results showed that adequate knowledge (≥70%) was observed only in 16.7% while there was not a single patient who answered all the questions in the correct fashion. Conclusion: Patients undergoing PCI had inadequate knowledge about the stents and post PCI pharmacotherapy.

Objectives: The objective of this study was to determine the predictive value of GRACE score for predicting obstructive coronary artery disease in patients with non ST-segment elevation myocardial infarction (NSTEMI). Methodology: This cross-sectional study was conducted at the largest public sector cardiac care center of the Pakistan between January 2020 and June 2020. In this study, we included adult patients diagnosed with NSTEMI and correlation of GRACE score was assessed with angiographic finding of obstructive CAD defined as ≥50% stenosis in the left main or ≥70% stenosis in other coronary arteries. Results: A total of 227 patients were included in this study, out of whom 72.2% (164) were male patients and mean age was 55.77 ± 9.15 years. Mean GRACE score was found to be 95.89 ± 21.15. On coronary angiography obstructive CAD was present in 84.6% (192) of the patients. Area under the cure for predicting obstructive CAD was 0.669 [0.552 to 0.785]. The optimal cutoff value of GRACE score was ≥ 84 with sensitivity of 79.7% [73.3% to 85.1%] and specificity of 57.1% [39.3% to 73.7%]. GRACE score of ≥ 84 was found to be an independent predictor of obstructive CAD with odds ratio of 4.33 [1.61 - 11.64; p=0.004] adjusted for gender, age, hypertension, diabetes, family history of CAD, and smoking. Conclusion: GRACE score has a moderate predictive value in predicting obstructive CAD in patients with NSTEMI. The optimal cutoff value of 84 is an independent predictor with good sensitivity but moderate specificity in predicting obstructive CAD.

Objectives: A conflict of evidence exists regarding the gender-based differences in outcomes after primary percutaneous coronary intervention (PCI), therefore, aim of this study was to compare the clinical characteristics, angiographic findings, and outcome of primary PCI for men and women. Methodology: Data for this study was extracted from a prospectively managed primary PCI database of the National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan. We included consecutive patients of either gender with STEMI undergone primary PCI. Data on clinical characteristics, angiographic finding, and post procedure outcomes for female were compared with male group and also with a propensity matched male cohort. Results: A total of 2400 patients were included with 421(17.5%) women. The mean age for the men and women were 54.44±11.16 and 57.17±11.01 years respectively; p<0.001. Women had significantly high prevalence of hypertension (61.0% vs. 39.1%; p<0.001), diabetes (37.1% vs. 23.9%; p<0.001), and obesity (18.5% vs. 13.5%; p=0.008). The median symptom onset to hospital arrival time was 216 [366-124] minutes vs. 180 [310-112] minutes; p=0.001 for women and men. In-hospital mortality rate was 3.8% vs. 2.5%; p=0.147 for female and unmatched male cohort, while it was 3.6% vs. 3.8%; p=0.855 for female and propensity matched male cohort. Conclusion: Gender-based differences persist in clinical profile of the patients with STEMI. Women are likely to be older in age with more diabetes, hypertension, and obesity. Gender-based difference in outcome of primary PCI is appears to be driven by differences in clinical profile as adjusted outcome is not different for men and women.

OBJECTIVES:In the present study, we analysed the incidence of no-reflow phenomenon, its clinical and procedural predictors, and associated in-hospital outcomes for the patients undergoing primary percutaneous coronary intervention (PCI). BACKGROUND:No-reflow phenomenon after primary PCI is a procedural complication associated with adverse post-procedure outcomes. METHODS:Data for this study were extracted from global registry, NCDR®, the site of National Institute of Cardiovascular Disease (NICVD), Karachi from July 2017 to March 2018. The demographic, clinical, and procedural characteristics, and in-hospital outcomes were analysed for the patients with and without no-reflow after primary PCI. RESULTS:Of total of 3255 patients, no-reflow phenomenon was found in 132 (4.1%) patients and it was associated with significantly higher in-hospitality mortality (6.8% vs. 2.9%; p = 0.01), cerebrovascular accident (1.5% vs. 0%; p < 0.001), post procedure bleeding (2.3% vs. 0.5%; p = 0.009), and cardiogenic shock (3.8% vs. 1.2%; p = 0.011). The multivariate analysis showed advanced age [odds ratio = 1.63, 95% confidence interval 1.09-2.44, p = 0.018], diabetes [1.66, 1.14-2.42, p = 0.009], prior history of CABG [8.70, 1.45-52.04, p = 0.018], low pre-procedure TIMI flow grade [2.04, 1.3-3.21, p = 0.002], longer length of target lesion [1.51, 1.06-2.16, p = 0.023], and 10 fold raised troponin I [1.55, 1.08-2.23, p = 0.018] were the independent predictors of no-reflow. CONCLUSIONS:In this selected group of patients, the no-reflow phenomenon after primary percutaneous coronary intervention is not that uncommon. It is associated with an increased risk of adverse post-procedure hospital course including mortality. Pathophysiology of the no-reflow phenomenon is complex and opaque, however, it can be predicted based on certain clinical and procedural characteristics.