Myocarditis mimicking acute coronary syndrome - the role of cardiac magnetic resonance imaging in the diagnosis

Myocarditis is an inflammatory disease of myocardium with a wide range of clinical presentations. Myocarditis may mimic acute coronary syndrome (ACS) and adequate differential diagnosis is not possible by conventional tests. Cardiac magnetic resonance (CMR) has emerged as a leading imaging modality in the diagnosis of myocarditis in such patients. Here, we report three cases of myocarditis mimicking ACS with normal coronary arteries. CMR was used for confirming the diagnosis of myocarditis in all three patients presented here

Long-term clinical outcomes of percutaneous coronary intervention in saphenous vein grafts in a low to middle-income country

Background: Revascularization of saphenous vein grafts (SVGs) is challenging and debated for the last few decades. The percutaneous revascularization of SVGs was reported to have poorer long-term outcomes than native coronary artery revascularization.Purpose: We aim to study the peri-procedural complications and long-term outcomes of the percutaneous revascularization of SVGs in a low-middle-income country.Methods: In this retrospective study, we included 110 patients who underwent percutaneous revascularization from January 2011 to March 2020 and followed them retrospectively for long-term outcomes and major adverse cardiovascular events.Results: The mean age was 71 ±9, and 81% were male. The most common reason for the presentation was non-ST segment elevation myocardial infarction (NSTEMI) (46%). The mean follow-up period of the study was 48±27 months. The most common comorbidity was hypertension (86%). A drug-eluting stent (80%) was placed in most of the patients, followed by a bare-metal stent (BMS) (14%) and percutaneous balloon angioplasty (POBA) (6%). We did not find any significant difference in major adverse cardiac events (MACE) (P=0.48), target vessel revascularization (TVR) (p=0.69), and target lesion revascularization (TLR) (p=0.54) with drug-eluting stent (DES) as compared to either BMS or POBA. The mean period from coronary artery bypass grafting (CABG) to SVG percutaneous coronary intervention (PCI) was 15± 5.5 years. Multivariate Cox regression analysis showed that an acute coronary syndrome (ACS) event, stroke, and female sex were independently associated with MACE.Conclusion: The long-term outcomes of SVG PCI are not affected by the types of stents. Female gender, ACS, and stroke are the independent predictors of MACE after SVG PCI, and statin therapy has a positive impact on the long-term outcomes of SVG PCI

Comparison of Clinical Outcomes of Calcified and Non-Calcified Coronary Artery Lesion Intervention Under IVUS Guidance

Objective: To evaluate the clinical results of intravascular ultrasound (IVUS)-guided intervention for calcified coronary artery lesions.Study design: Observational study. Place and Duration of the Study: Department of Medicine, The Aga Khan University Hospital, Karachi, from January 2013 to January 2020.Methodology: A cohort of 134 consecutive patients who underwent intravascular ultrasonography-guided assessment of coronary arteries were included. Patients were divided into two groups: those with coronary artery calcification (CAC, n=77) and those without (non-CAC, n=57). The two groups were compared for their clinical characteristics, management, in-hospital events, follow-up, and major adverse cardiovascular events (MACEs).Results: The mean follow-up duration was 40.3 ± 30.1 months. Most of the patients were male (n=97, 72.3%), and the mean age was 63.1 ± 12.9 years. In the CAC group, age was the most common risk factor, followed by dyslipidaemia (n=68, 88%), hypertension (n=64, 83%), and Diabetes mellitus (n=44, 57%). CAC group patients were more commonly presented with acute coronary syndrome (n=59, 76.6%), had prior PCI (n=40, 52%), had more LM disease (n=34, 44%, p=0.005), and a significant number of prior stent-ISR (n=27, 35%, p=0.024). Those who had CAC had higher MACE.Conclusion: Patients with CAC had more co-morbidities and commonly presented with acute coronary syndrome. MACEs frequency was recorded higher in the CAC group although the results were not statistically significant

Clinical characteristics and prognostic factors of atrial fibrillation at a tertiary center of Pakistan – from a South-Asian perspective – A cross-sectional study

Background: There is lack of large data from South-Asian region on atrial fibrillation and it is imperative that clinical presentation, prognostic factors, management pursued, and outcomes are known for this part of the world. Once collective evidence for the region is known, region-specific guidelines can be laid forward. Objectives: To evaluate clinical characteristics and prognostic factors of atrial fibrillation at a tertiary care center of Pakistan. Methods: This was a retrospective study conducted at a tertiary care center of Pakistan. Period of study ranged from July-December 2018. All hospitalized patients who were admitted with atrial fibrillation as a primary or associated diagnosis were enrolled. Results: A total of 636 patients were enrolled. The mean age was 68.5 ± 12 years and 49.5% (315) were male. 90.6% of the patients were admitted via emergency room. Majority (59.9%) had previously known AF and 40% developed new-onset AF during the hospital stay. Hypertension was the most common co-morbid condition (85.4%) followed by Diabetes Mellitus (40.1%). At least 9% had rheumatic heart disease. The median CHA2DS2VASc and HASBLED scores were 4 and 2 respectively. More than one-third of patients had sepsis as a primary diagnosis (36.8%). The in-hospital mortality of patients with atrial fibrillation was 6.7%. Patients with new-onset AF had higher mortality. Sepsis and stroke were independently associated with a higher mortality. There was no significant difference in median CHA2DS2VASc and HASBLED scores for patients with new-onset and previously known AF. On discharge, 83% of the eligible patients received oral anticoagulation. Conclusion: There was higher prevalence of chronic co-morbid conditions in the studied population leading to a higher CHA2DS2VASC Score. Sepsis and stroke were independently associated with higher in-hospital mortality

Leveraging clinical digitized data to understand temporal characteristics and outcomes of acute myocardial infarctions at a tertiary care medical centre in Pakistan from 1988-2018 - Methods and results

Background and objective: Few data exist on trends in acute myocardial infarction (AMI) patterns spanning recent epidemiological shifts in low middle-income countries (LMICs). To understand temporal disease patterns of AMI characteristics and outcomes between 1988-2018, we used digitized legacy clinical data at a large tertiary care centre in Pakistan.Methods: We reviewed digital health information capture systems maintained across the Aga Khan University Hospital and obtained structured elements to create a master dataset. We included index admissions of patients \u3e18 years that were discharged between January 1, 1988, and December 31, 2018, with a primary discharge diagnosis of AMI (using ICD-9 diagnoses). The outcome evaluated was in-hospital mortality.Clinical characteristics derived from the electronic database were validated against chart review in a random sample of cases (k 0.53-1.00).Results: The final population consisted of 14,601 patients of which 30.6% (n = 4,470) were female, 52.4% (n = 7,651) had ST elevation MI and 47.6% (n = 6,950) had non-ST elevation MI. The median (IQR) age at presentation was 61 (52-70) years. Overall unadjusted in-hospital mortality was 10.3%. Across the time period, increasing trends were noted for the following characteristics: age, proportion of women, prevalence of hypertension, diabetes, proportion with NSTEMI (all ptrend \u3c 0.001). In-hospital mortality rates declined significantly between 1988-1997 and 2008-2018 (13.8% to 9.2%, p \u3c 0.001).Conclusions: The patterns of AMI have changed over the last three decades with a concomitant decline in in-hospital mortality at a tertiary care centre in Pakistan. Clinical digitized data presents a unique opportunity for gaining insights into disease patterns in LMICs