Background: Cardiac complications remain a major cause of perioperative morbidity and mortality globally among patients undergoing noncardiac surgery. In Nepal, implementing international guidelines is challenging due to resource constraints, workforce variability, and a high burden of rheumatic heart disease, early-onset coronary artery disease and chronic obstructive pulmonary diseases. Objective: To develop standardized, evidence-based recommendations for preoperative cardiac evaluation for adult patients undergoing noncardiac surgeries focussed on Nepalese context. Methods: Cardiac Society of Nepal coordinated a three-round modified Delphi process amongst cardiologists, anesthesiologists, and surgeons from healthcare institutions across Nepal. The AGREE II framework guided guideline development, and DELPHISTAR standards ensured transparent reporting. Consensus was defined as >= 70% "Strongly Agree" or >= 80% "Strongly Agree + Agree". Results: Consensus was achieved on 26 key recommendations covering screening, risk stratification, prehabilitation, surgical and institutional considerations. These recommendations adapt international best practices to Nepal's specific challenges, prioritizing low cost tests like ECG, selective use of echocardiography and biomarkers, and addressing modifiable risk factors preoperatively. Conclusion: This multidisciplinary consensus provides a context-appropriate, pragmatic framework for preoperative cardiac evaluation in Nepal. It aims to improve perioperative outcomes, support coordinated perioperative care, and guide national perioperative quality standards and future research.

Introduction: Patients with Atrial fbrillation (AF) are at fivefold higher risk for Ischemic stroke than in the general population. Although the current therapeutic guidelines recommend the use of anticoagulants for thromboembolic prophylaxis in patients with nonvalvular AF (NVAF) with additional risk factor(s) for stroke, the global registry data show non-adherence to guidelines for the management of stroke in diferent regions of the world. The current study conducted at the tertiary referral cardiac center of Nepal for addressing the risk profle of stroke based on the current risk scores and the use of antithrombotic agents NVAF patients. Methodology: This was a descriptive observational cross sectional study conducted at Shahid Gangalal National Heart Centre (SGNHC), Kathmandu, Nepal from December 2020 to June 2020 which included patients with Nonvalvular AF. The main objective of the study was to study the clinical characteristics, stroke risk profle based on CHA ₂DS₂-VaSc score and risk of bleeding based on HAS-BLED score and the patterns of use of antithrombotic agents in NVAF patients. Results: A total of 79 cases of NVAF were included with 48(60.8%) males and 31(39.2%) females. The mean CHA₂DS₂-VaSc and HAS-BLED score were 2.44±1.2 and 1.51±1.4 respectively. The majority patients 38% had permanent AF followed by 25.5% had paroxysmal AF. Majority of patients were symptomatic with 67.1% presented with palpitation while 32.9% presented with shortness of breath (SOB). Based on the European Heart Rhythm Association (EHRA) AF related symptoms score, 41.8% had EHRA 2a and 2b while 1.3% had EHRA 4 score. The use of anticoagulants in patients with Nonvalvular AF was 41.6%, with NOACS in 33 % and warfarin used in 8.9% cases. The majority of patients 51.8% of study population were using anti-platelet agents with aspirin in 49.3 % and clopidogrel in 2.5 % cases while no medication in 6.3% of cases. Although 70.8% patients had CHA₂DS₂-VaSc score of 2 or more but the use of anticoagulants was only 58.9% with 46.4% NOACS and 12.5% using warfarin among this group of patients. Conclusion: Although the use of anticoagulant with NOACS in patients with higher risk of stroke is increasing, it is still underused in the majority of cases .There is a need of nationwide AF registry and the need of adoption of the current recommended guidelines to increase use of Anticoagulants in patients with Nonvalvular AF patients for the prevention of stroke .

Background and Aims: Cardiovascular comorbidities are common in patients with COVID-19 and these patients are at higher risk of morbidity and mortality. It is not known if the presence of cardiovascular co-morbid conditions poses independent risk or whether this is mediated by other factors. Methods: This is a retrospective follow up study done at Shahid Gangalal National Heart Centre (SGNHC). The main objective of this study was to study the clinical profile, baseline comorbidities, and outcome of cardiac patients and health care worker diagnosed with COVID 19. This study retrospectively evaluated case records of all cardiovascular disease (CVD) patients admitted at SGNHC with COVID 19 cases from 1st case diagnosed on July at SGNHC till September 2020. Results: During this study period, 90 patients with COVID 19 with cardiovascular disease were admitted. The mean age of the study population was 52.3±19 years with 65.6% being male. Among the study population 52 (57.8%) had past history of cardiovascular disease, hypertension in 18 (20%) cases, diabetes in 8 (8.9%) cases. Among the patients with cardiovascular diagnosis, acute coronary syndrome was most common cardiovascular diagnosis in 23 (25.6% cases) followed by rheumatic heart disease in 21 (23.4%) cases, dilated cardiomyopathy in 7 (7.8% cases), ischemic cardiomyopathy with reduced ejection fraction (EF) in 7 (7.8%) cases, post coronary artery bypass graft (CABG) in 8 (8.9%), post valve replacement in 5 (5.5%), congenital heart disease in 3.3% cases and complete heart block in 3.3% cases. Most of the cases were symptomatic with moderate illness in 46.7% cases, mild illness in 41.4% cases and severe/critical illness in 11.1% cases. Among COVID patients with cardiovascular disease, the mortality was 11.1%. Conclusion: Patients with cardiovascular disease with COVID 19 have more severe COVID 19 symptoms and has higher COVID 19 related death, so strict vigilance and early intervention is needed to improve its outcome.

Background and Aims: The number of pacemaker implantation is increasing at various centres of Nepal with increase in cardiac services. However, there are few data available regarding the pacemaker implantation in Nepal. This study intend to focus and study trends and profile of permanent pacemaker implantation (PPI) of 19 years experience at the referral tertiary cardiac center which will reflect intended objective of this study. Methods: This was a retrospective cross sectional study done at Shahid Gangalal National Heart Centre (SGNHC). The data of the patient who underwent PPI from 2001 November to 2020 August were reviewed. Patients data including age, sex, indication for pacing, mode of pacing, type of pacemaker implanted, implantation parameters such as lead impedence and threshold were recorded and analyzed. Results: A total of 3631 pacemaker implantation were performed at SGNHC from 2001 November to 2020 August. Among the total patients, 59.4% were male with mean age of 65.2±15.2 years. The most common indication was degenerative complete heart block (74.8%). Sick sinus syndrome (8.2%) was the second most common indication of pacing. The single chamber were implanted in 93.3% cases and dual chamber in 6.7% cases. VVIR was the most common mode of implantation in 93.1% cases, followed by DDDR (6.7%). AAIR (0.1%) and VDD in 0.1% cases. The total number of pacemaker implanted yearly in SGNHC has increased since the early year of implantation. During the early years most of the pacemakers were Single chamber (VVI) pacemaker and the implantation of dual chamber pacemaker increased gradually from year 2010 onwards. After the year 2010 the implantation of dual chamber pacemaker has increased significantly compared to prior to 2010 (p= 0.001). There were no gender differences in use of single chamber and dual chamber implantation during this period. (p value = 0.489). The dual chamber were implanted mostly in age group less than 65 year compared to more than 65 years (P value = 0.001). Conclusion: There is gradual increase in the number of pacemaker implantation yearly at SGNHC and since 2010 there is also increase in number of dual chamber pacemaker implantation though the single chamber pacemaker outnumbered the dual chamber implantation.

Background and Aims: Idiopathic ventricular arrhythmia (IVAs) is defined as premature ventricular complexes (PVCs), nonsustained ventricular tachycardia or sustained ventricular tachycardia (VT) in the absence of obvious structural heart disease. Catheter ablation has become an established treatment strategy for wide varieties of idiopathic ventricular arrhythmias. The aim of this study is to report the efficacy and safety of catheter ablation of idiopathic ventricular arrhythmias, for the first time in Nepal. Methods: This is a retrospective observational descriptive study of all patients who underwent electrophysiological study and radiofrequency catheter ablation for IVAs from March, 2015 to February 2020 at Shahid Gangalal National Heart center (SGNHC). Results: Altogether 101 patients underwent an EP study with intent to ablations for idiopathic ventricular arrhythmias. In 13 patients, ventricular arrhythmias were not present on the procedure day and also could not be induced in the lab, therefore ablation was performed in 88 patients only. RVOT was the most common site of these arrhythmias comprising 51% of all cases, followed by fascicular VT (34%) and basal left ventricular IVAs (15%). Out of 88 patients, the acute success of 7 patients could not be assessed because of very infrequent PVCs. Out of remaining 81 patients, acute success achieved in 77 patients (95%). Recurrence occurred in 9 patients (10.7%) and 4 patients underwent repeat ablation giving rise to over clinical success during follow up in 78 patients (88.7%). There were two major complications, one pulmonary embolism and another cardiac tamponade both managed successfully. Conclusion: This single-center single operator study demonstrates that catheter ablation of idiopathic ventricular arrhythmias has a high success and low complication rate

Background and Aims: Atrial tachycardia is classified as focal atrial tachycardia or macro-reentrant atrial tachycardia. Macro-reentrant atrial tachycardia involves large circuit and is also called atrial flutter in which cavotricuspid isthmus dependent flutter, also called typical atrial flutter is the most common. The aim of this study is to report the efficacy and safety of catheter ablations of these arrhythmias, for the first time in Nepal. Methods: This is a retrospective observational study of the patients who underwent electrophysiological study with ablation for focal atrial tachycardia and typical atrial flutters at Shahid Gangalal National Heart Center (SGNHC) from March, 2015 to February 2020. Results: Altogether, 49 patients, 27 for focal atrial tachycardia and 22 for typical atrial flutter, underwent electrophysiology study with intent to ablation. In two patients, atrial tachycardia could not be induced, therefore 25 patients underwent ablation for atrial tachycardia. Out of 25 patients, the successful ablation achieved in 24 patients (96%) with recurrence in three patients (12%), with no major complications. Atrial tachycardia more commonly originated from right atrium than the left atrium (68% vs. 32%). Among 22 patients who underwent cavotricuspid isthmus ablation for typical atrial flutter; successful ablation achieved in 21 patients (95%) with recurrence in two patients (9%) and a single case of access site hematoma. Counterclockwise flutter was found to be more common than clockwise flutter (91% vs. 9%). Conclusion: In SGNHC, the ablations of focal atrial tachycardia and the typical atrial flutter has a high success and low complication rate.

Background and Aims: Incidence of ST-elevation myocardial infarction (STEMI) is increasing in Nepal. We aim to describe the presentation, management, complications, and outcomes of patients admitted with a diagnosis of STEMI in Shahid Gangalal National Heart Centre (SGNHC), Nepal. Methods: Shahid Gangalal National Heart Centre-ST-elevation registry (SGNHC-STEMI) registry was a cross sectional, observational, registry. All the patients who were admitted with the diagnosis of STEMI from January 2018 to December 2018 were included. Results: In this registry, 1460 patients out of 1486 patients who attended emergency were included. The mean age of patients was 60.8±13.4 years (range: 20 years to 98 years) with 70.3% male patients. Most of the patients (83.2%) were referred from other hospitals and 16.8% of patients directly attended the SGNHC emergency. During the presentation, smoking (54%) was the most common risk factor, followed by hypertension (36.6%), diabetes mellitus (25.3%), and dyslipidemia (7.8%). After admission, new cases of dyslipidemia, HTN, Impaired Fasting Glucose (IFG), and Type 2 DM were diagnosed in 682 (51.3%), 182 (20.1%), 148 (10.3%) and 95 (8.9%) respectively. At the time of presentation, 73.3% were in Killip class I and 26.3% were above Killip class II with 5.1% in cardiogenic shock. Thirty-one percent of the cases received reperfusion therapy (Primary percutaneous intervention in 25.2% and fibrinolysis in 5.8%). Inferior wall MI was the most common type of STEMI. Among the patients who underwent invasive therapy, the multi-vessel disease was noted in 46.2% cases and left main coronary artery involvement in 0.7% cases. In-hospital mortality was 6.2% with cardiogenic shock being the most common cause. Aspirin (97.8%), clopidogrel (96.2%), statin (96.4%), ACEI/ARB (76.8%) and beta-blocker (76.8%) were prescribed during discharge. Conclusion: The SGNHC-STEMI registry provides valuable information on the overall aspect of STEMI in Nepal. In general, the SGNHC-STEMI registry findings are consistent with other international data.

Background and Aims: Cardiac resynchronization therapy (CRT) has become an established treatment modality for patients with advanced heart failure. CRT abbreviates the dysynchronus heart failure mainly by correcting left ventricular dysynchrony. In the last three years, CRT has been regularly done in Shahid Gangalal National Heart Center(SGNHC) which has provided us the platform to report the outcome of CRT, for the first time in Nepal. The aim of this study is to review the recent clinical experience and outcome of CRT in our centre. Methods: All consecutive patients who underwent CRT at SGNHC from July, 2016 to July, 2019 were reviewed retrospectively. Results: Altogether 42 patients underwent CRT. Mean age was 65±11 years (range 43 to 84). Coronary sinus cannulation was successful in 41 patients. In one patient, LV lead delivery was unsuccessful. Thus, procedural success was obtained in 95% (40 out of 42) patients. LV lead dislodgement occurred in three patients (7%). Coronary sinus dissection occurred in two patients (5%). Biventricular (BiV) paced QRS was significantly narrower compared to baseline QRS (127ms Vs 162ms, p<0.01). During mean follow up of 12±10 months (range 1 to 30 months), there was significant improvement in the clinical outcomes: NYHA class (1.8 Vs 2.9, p<0.01), LVEF (22.3 Vs 27.5, p<0.01), left ventricle internal diameter in systole (LVIDs), (57 Vs 60.5 mm, p<0.01). The CRT responder rate was 86%. Super-responder was observed in 12% of patients. Conclusion: In SGNHC, Cardiac resynchronization therapy is emerging as a routine treatment strategy with a reasonable efficacy and safety outcome.

Background and Aims: Heart failure is a major global health problem, but studies on prevalence of heart disease in Nepal are sparse. The aim of this study is to describe the etiology of heart failure patients in emergency department of Shahid Gangalal National Heart Centre.Methods: This was a single centre, prospective, observational study, conducted in the Emergency Department of National Heart Centre, from 1st May to 30th August 2016. All (n=591) consecutive patients with clinical diagnosis of heart failure were evaluated.Results: The mean age of the patients was 56.48 ±19.44 years, with 45.9% males. 31.3% had atrial fibrillation. The commonest cause of heart failure was rheumatic heart disease (25.1%), followed by dilated cardiomyopathy (22.8%), and coronary artery disease (18.1%). The commonest causes in the age group ≤44 years were rheumatic heart disease (61.9%), and congenital heart disease (11.0%). Commonest causes in the age groups 45 – 64 years and ≥ 65 years were dilated cardiomyopathy (29.0% and 26.4%, respectively) and coronary artery disease (22.3% and 24.3%, respectively). The commonest causes in male was dilated cardiomyopathy (26.9%) and in female it was rheumatic heart disease (31.6%).Conclusion: Rheumatic heart disease, dilated cardiomyopathy and coronary artery disease are the commonest cause of heart failure. Appropriate prevention strategies focused at these causes of heart failure are required to decrease the burden of heart failure in Nepal.Nepalese Heart Journal 2017; Vol 14(2), 1-4

In context of rapidly rising prevalence of cardiovascular disease and risk factors in the developing world it has become important to study the scenario in its various aspects. This study conducted between March and July, 2007 in a suburban Nepali population deals with prevalence of metabolic syndrome according to the recently modified criteria for Asians. Altogether 150 subjects were randomly selected. The main component of the survey included administration of predetermined questionnaire, physical examination which included waist circumference measurement, height, weight, blood pressure measurement (twice), 12-lead ECG and fasting blood sample for lipid profile and glucose level. Prevalence of metabolic syndrome in our study according to the recent criteria developed by AHA/NHBLI is 12.4%. Significant Proportion of subjects diagnosed as having metabolic syndrome was not obese by traditional criteria but had increased waist circumference. Elevated triglyceride level was the most common component among subjects with metabolic syndrome was not obese by traditional criteria but had increased waist circumference. Elevated triglyceride level was the most common component among subjects with metabolic syndrome. Prevalence of metabolic syndrome syndrome in a suburban Nepali community seems to be significant. Thus, it is time for the developing countries to realize that the prevention of non-communicable diseases should also receive as much attention as that of nutritional and communicable diseases.

The role of major cardiovascular risk factors in the development of coronary artery disease (CAD) is well established and is fairly similar in both sexes. However, CAD is markedly more common in male than in female, and this is due to more risk factors, especially smoking and dyslipidemia, in male. In this study, we aim to investigate the five major risk factors as defined by ACC-AHA namely, advancing age, smoking, hypertension, diabetes and dyslipidemia, in the MI patients admitted in CCU, SGNHC from Jan 1 to June 30th 2008 and to compare whether the association of those risk factors with CAD risk is similar in male and female. There were altogether 283 MI patients, Male 208 (73%) and Female 75 (27%). Advancing age was the most common comprising 85.2% followed by smoking 55.5%, Hypertension 48.1%, Dyslipidemia 47% and Diabetes 24.7%. Smoking, dyslipidemia and advancing age were significantly more common in male. Male patients have significantly more risk factors than female. There was trend towards the greater number of high total cholesterol and low HDL in male patients. Advancing age (Male 45 yrs, Female 55 yrs) is the commonest risk factor of CAD. Smoking and dyslipidemia (especially high total cholesterol and low HDL) are significantly more common in male which might have contributed markedly to the excess CAD risk in males.

Background and aims: Acute coronary syndrome (ACS), which comprises acute ST-segment elevation myocardial infarction, non-ST segment elevation myocardial infarction and unstable angina is a major health problem and represents a large number of hospitalizations annually worldwide. We aim to describe pattern of the ACS admission and in-hospital mortality at tertiary national heart centre of the country. Methods: A hospital database was used to analyze all 7424 patients admitted in coronary care unit of the centre for ACS from September 2001 till December 2012. We evaluated trend of ACS admission and in-hospital mortality. Results: Five thousand three hundred ninety one (72.6%) were male and two thousand thirty three (27.4%) were female. Patient of 21years to 98 years were admitted for ACS .Four thousand five hundred and ninety nine(61.9%) patient were admitted due to ST elevation myocardial infarction, whereas one thousand nine hundred and thirteen (25.8%) were admitted for Unstable angina and nine hundred twelve (12.3%) were admitted for Non ST elevation myocardial infarction. In-hospital mortality was 5.74% for acute coronary syndrome. There was significant difference in in-hospital mortality between ST elevation myocardial infarction (7.76%), Non ST segment elevation acute coronary syndrome (3.61%) and Unstable Angina (1.88%).There is a gradual increase in Primary Percutaneous Coronary intervention as a mode of reperfusion therapy whereas there is a decrease in the rate of thrombolysis. Conclusion: Our study provides us some important information about the trend and in-hospital mortality rate in national heart centre. Though it is a single centre study can provide us the insight of the ACS outcome. DOI: http://dx.doi.org/10.3126/jaim.v3i1.10698 Journal of Advances in Internal Medicine 2014;03(01):23-26

Background and aims - Lipoprotein(a) is not an established independent risk factor. This study aims to observe whether lipoproteina(Lpa) is significantly high in patients of acute coronary syndrome (ACS) in comparison to healthy control. The second part of the study is aimed to know whether oral nicotinic acid treatment lowers Lpa level significantly. Methods - This is a prospective case control study with quasi-experimental design done on acute coronary cases admitted in our centre. Total 200 cases of ACS were included as cases and 46 healthy volunteers were controls. In later part of the study those patients who had high Lpa and were eligible were treated with nicotinic acid for 3 months and Lpa was measured again. Results - Mean Lp(a) level was 39.7mg/dl (±17) among the 200 ACS cases admitted in CCU with the maximum of 83 and minimum of 14. Among controls mean Lpa was 22mg/dl (±3.04) with maximum of 44 and minimum of 17mg/dl. Difference was significant with p value of < 0.01. It was observed that nobody discontinued the drug because of side-effects. In these patients there was significant reduction in serum Lpa level from 74.1mg/dl (± SD22.2) to 43.2mg/ dl (± SD21.9) p<0.01. Conclusion - The serum level of Lpa was significantly high in patients with ACS patients in comparison to control. This difference however was not significant between STEMI and NSTEMI patients. Low dose Nicotinic acid reduces Lpa significantly and is well tolerated by the patients. DOI: http://dx.doi.org/10.3126/jaim.v2i2.8778 Journal of Advances in Internal Medicine 2013;02(02):61-64

Background and Aims- Reperfusion therapy is indicated for patient with acute ST Elevation Myocardial Infarction. Several randomized trials and meta-analyses have shown that Primary Percutaneous Coronary Intervention is better than thrombolysis. Our aim was to determine the outcomes of Primary Percutaneous Coronary Intervention in Shahid Gangalal National Heart Centre, Nepal. Methods- Medical records of 212 Primary Percutaneous Coronary Intervention from March 2007 to March 2012 were retrospectively reviewed. The primary end point was in-hospital mortality and secondary end points were 30 day mortality and long term mortality. Results- In the patients presenting to emergency with acute ST elevation myocardial infarction, inferior wall Myocardial Infarction 64 (30%) was the most common. Single vessel disease 168 (79%) predominated in emergency coronary angiogram. In majority of the patients Right Coronary Artery 103 (48.7%) was the culprit vessel. Cardiogenic shock was present in 28 (13.2%) patients. There were 11 deaths (39.2%) in cardiogenic shock group where as only 5 deaths (2.7%) among 184 non cardiogenic shock patients, resulting in in hospital mortality rate of 7.5%. Among the 196 patients who were successfully discharged from the hospital, 21 patients lost to follow up. There was one death reported within a month, non within three months and four within a year post discharge from the hospital. Conclusions- The result of this study is comparable to the findings elsewhere in the world. Primary Percutaneous Coronary Intervention should be the treatment of choice in treating acute myocardial infarction where the facilities and the expertise are available. Journal of Advances in Internal Medicine 2013;02(01):6-9 DOI: http://dx.doi.org/10.3126/jaim.v2i1.7629

Retraction: Rajbhandari S, et al. Cardiac Resynchronization Therapy for Heart Failure. Journal of Advances in Internal Medicine 2012;01(02):65-8. It was brought to our attention that the article, "Cardiac Resynchronization Therapy for Heart Failure" JAIM | volume 01 issue 02 | July-December 2012 page 65, contains this passage in its introduction: “Heart failure is a clinical syndrome resulting from a structural and functional disorder of the heart that impairs the ability of the ventricles to fill with or eject blood to fulfil the demands of the body, or does so in expense of increased filling pressures.” Unfortunately, this passage is not attributed and was taken from an earlier publication: http://informahealthcare.com/doi/ abs/10.3109/9780203089965.001. There are additional instances of plagiarism in the article. Given the weight of evidence offered in the report by Jeffrey Beall (Associate Professor, Scholarly Initiatives Librarian, Auraria Library, University of Colorado Denver, 1100 Lawrence Street, Denver, Colorado 80204 USA), the article has been retracted from the journal JAIM | volume 01 issue 02 | July-December 2012, page 65-8. DOI of Retraction notice: http://dx.doi.org/10.3126/jaim.v2i2.8783 DOI of original article: http://dx.doi.org/10.3126/jaim.v1i2.6528 Journal of Advances in Internal Medicine 2012;01(02):65-68

Heart failure is the final common pathway of all heart diseases and is the major cause of morbidity and mortality. Approximately 1/3rd of patients with heart failure have wide QRS causing ventricular dyssynchrony which results in various mechanical consequences aggravating the heart failure. This can be addressed by a biventricular pacing device which can rectify that problem. Cardiac Resyn chronization Therapy (CRT) is the simultaneous pacing of the left and right ventricles following atrial contraction using a biventricular pacemaker to restore ventricular contraction synchrony in patients who have heart failure accompanied with ventricular dyssynchrony. Numerous trials have shown that such therapy has improved the symptoms and decreased mortality in conjunction with optimal medical treatment. Accepted on

Shahid Gangalal National Heart Center (SGNHC) is the first and the only one facility providing electrophysiological studies (EPS) and radiofrequency catheter ablation (RFCA) for supraventricular tachycardia in Nepal. The first RFCA for SVT in Nepal was performed on 13th October 2003 with Portable EP lab (EP Tracer-Johnson & Johnson). To date, total of 248 RFCA procedures have been performed in SGNHC. The retrospective analysis of this patients population has provided an opportunity to narrate our initial experience regarding baseline characteristics, EP findings, immediate and follow up outcomes and complications.

Nepal is a small (area 143,000 km2) landlocked country situated in South Asia and is one of the poorest countries in the world. Its population is approximately 24.7 million, and the doctor/patient ratio is 1:10,000. People living in Nepal are largely dependent on farming, and the vast majority of the population lives below the poverty line. The population is multiracial and multilingual. The country currently is emerging from major political, economic, and social upheaval.

Glycoprotein IIb/IIIa receptors are the most common receptor subtypes on the platelet surface. During vessel injury, the sub-endothelial layer is exposed so that platelets adhere to sub-endothelial collagen via la/Ila receptor and to von Willebrand factor via glycoprotein Ib receptor. Adherent platelets are activated by ADP, 5-HT, TXA2 etc which result in the conformational change of platelets, thereby activating nearly 80,000 GP IIb/IIIa receptors on platelet surface. These activated receptors bind fibrinogen to fascilate the formation of a platelet plug.1,2