Outcomes of Left Main Percutaneous Coronary Intervention

Objective: To study the outcomes of left main percutaneous coronary artery (LMCA) revascularisation. Study Design: A descriptive study. Place and Duration of Study: The Aga Khan University Hospital (AKUH), Karachi, from February till July 2016. Methodology: The study included all adult patients aged 18 years or more, who underwent percutaneous LMCA revascularisation at study centre from April 2006 till April 2015. In-hospital outcomes were ascertained of patients via charts along with telephonic follow-up for outcome ascertainment at 1-year and 5-year. Results were expressed in terms of means and standard deviation for quantitative variables and percentages for qualitative variables. Results: Of the 86 patients, the mean age was 66.05 ±12.6 years and 69% (59 cases, n=86) of them were males. Sixteen (18.6%) patients presented with cardiogenic shock and 17.4% (15 cases, n=86) required mechanical ventilation upon arrival. Among the 86 patients, 23.3% (20 patients, n=86) underwent PCI because of unstable condition for CABG and refusal by the surgeons. Mean follow up time for participants was 40.5 ±25.7 months with mean length of hospital stay of 4.36 ±2.4 days. In-hospital mortality was 12.8%, while mortality at 1-year and at mean follow-up was 7.3% and 6.9%, respectively. Conclusion: LM percutaneous coronary intervention is a viable option for patients who are hemodynamicaly unstable and require urgent revascularisation or for patients denying bypass surgery due to other reasons in Pakistan. Prospective studies in future may be required to evaluate the role of PCI for LM lesions in elective setting in contrast to existing treatment options

Severity of Chest Pain among Acute Myocardial Infarction Patients with Diagonal Branch Vessel Disease: A Pilot Study

Introduction: Acute myocardial infarction (AMI) patients present with variable clinical manifestations such as shortness of breath, nausea, etc. among which chest pain is the most common. Previous studies have reported that the clinical presentation of AMI patients with branch vessel disease is indistinguishable from epicardial coronary vessel disease. However, our experience suggests patients with branch vessel disease experience severe chest pain, especially those with a diagonal branch. Therefore, we aim to study the association of chest pain severity with isolated diagonal branch vessel disease as a culprit vessel in AMI patients. Methods: It is a retrospective case-control design, where 10 cases and 40 historic controls were recruited in the study. Cases were patients with isolated diagonal branch disease, whereas controls were patients with epicardial vessel disease in AMI. We reviewed Coronary Angiograms of adult patients who presented with acute myocardial infarction and had undergone coronary angiography at Aga Khan University Hospital, Karachi (AKUH). Information on pain scores was measured using the Numeric Pain Rating Scale (NRS) before administration of analgesics. Other relevant variables were also recorded on a pre-structured questionnaire. Results: The mean age of all the participants in the study was 60 ± 11.0 years, with 16% of the patients being women. Among all AMI patients, the intensity of chest pain in patients with isolated diagonal branch vessel disease was 2.6 units higher as compared to those with other epicardial coronary vessel diseases (p-value: \u3c0.001; 95% CI: 1.67 - 3.46). Conclusion: This preliminary study indicates severe chest pain can be a differentiating symptom in AMI patients with diagonal branch disease. It emphasizes clinicians to look for a possibility of a diagonal branch as a culprit vessel in AMI for better judgment, as it is often overlooked. future studies may be conducted at multiple centers for larger sample size and better generalizability

Defining the hemodynamic response of hypertensive and normotensive subjects through serial timed blood pressure readings in the clinic

Background: Every third patient in the clinic is misdiagnosed due to white-coat phenomenon, necessitating needless and costly treatment. We aimed to study the hemodynamic response of the physician\u27s visit on hypertensive and normotensive patients by investigating the trend of blood pressure (BP) before, during and 15 min after the physician-patient encounter.Methods: A descriptive, cross-sectional study was conducted over a period of 8 months in the cardiology clinics at the Aga Khan University Hospital, Karachi. Both hypertensive and normotensive patients, aged ≥18 years, were recruited. Pregnant females or those with a history of volume loss were excluded. BP readings were taken using an automated, validated device (Omron-HEM7221-E) at three points: pre-clinic BP by the assessment nurse, in-clinic BP by the attending physician and post-clinic BP 15-min after the physician-patient encounter by a research assistant. Independent samples t-test was used to calculate the statistical difference between hypertensive and normotensive BP values.Results: Of 180 participants, 71% (n = 128) were hypertensive and 57% (n = 103) of all were males. The mean age of the participants was 57 ± 15 years. The mean and standard deviation(±SD) systolic BP (SBP) taken pre-clinic, in-clinic and 15-min post-clinic for hypertensive population was 128.7 ± 20 mmHg, 137.1 ± 21 mmHg and 127.9 ± 19 mmHg. The mean and standard deviation(±SD) SBP taken pre-clinic, in-clinic and 15 min post-clinic for normotensive population was 112 ± 16 mmHg, 115.8 ± 20 mmHg and 111.8 ± 15 mmHg. The hypertensive SBP values showed statistically significant difference from the normotensive values (difference in pre-clinic SBP: 16.7 mmHg, p-value \u3c 0.001; in-clinic SBP: 21.3 mmHg, p-value \u3c 0.001; and 15 min post-clinic: 16.1 mmHg, p-value \u3c 0.001).Conclusions: Hypertensive and normotensive patients display congruent hemodynamics upon visiting the physician, the alert response being accentuated amongst the hypertensive group. In-clinic BP readings are higher for both hypertensive and normotensive patients making them unreliable for screening and management of hypertension amongst both the groups

Adaptation of the Recent Life Changes Questionnaire (RLCQ) to measure stressful life events in adults residing in an urban megapolis in Pakistan

Background: Contextually relevant stressful life events are integral to the quantification of stress. None such measures have been adapted for the Pakistani population. Methods: The RLCQ developed by Richard Rahe measures stress of an individual through recording the experience of life changing events. We used qualitative methodology in order to identify contextually relevant stressors in an open ended format, using serial in-depth interviews until thematic saturation of reported stressful life events was achieved. In our next phase of adaptation, our objective was to scale each item on the questionnaire, so as to weigh each of these identified events, in terms of severity of stress. This scaling exercise was performed on 200 random participants residing in the four communities of Karachi namely Kharadar, Dhorajee, Gulshan and Garden. For analysis of the scaled tool, exploratory factor analysis was used to inform structuring. Finally, to complete the process of adaption, content and face validity exercises were performed. Content validity by subject expert review and face validity was performed by translation and back translation of the adapted RLCQ. This yielded our final adapted tool. Results: Stressful life events emerging from the qualitative phase of the study reflect daily life stressors arising from the unstable socio-political environment. Some such events were public harassment, robbery/theft, missed life opportunities due to nepotism, extortion and threats, being a victim of state sponsored brutality, lack of electricity, water, sanitation, fuel, destruction due to natural disasters and direct or media based exposure to suicide bombing in the city. Personal or societal based relevant stressors included male child preference, having an unmarried middle aged daughter, lack of empowerment and respect reported by females. The finally adapted RLCQ incorporated Environmental Stress as a new category. Conclusion: The processes of qualitative methodology, in depth interview, community based scaling and face and content validity yielded an adapted RLCQ that represents contextually relevant life stress for adults residing in urban Pakistan

Geo-spatial reporting for monitoring of household immunization coverage through mobile phones: Findings from a feasibility study

Background: The addition of Global Positioning System (GPS) to a mobile phone makes it a very powerful tool for surveillance and monitoring coverage of health programs. This technology enables transfer of data directly into computer applications and cross-references to Geographic Information Systems (GIS) maps, which enhances assessment of coverage and trends.Objective: Utilization of these systems in low and middle income countries is currently limited, particularly for immunization coverageassessments and polio vaccination campaigns. We piloted the use of this system and discussed its potential to improve the efficiency of field-based health providers and health managers for monitoring of the immunization program.Methods: Using 30×7 WHO sampling technique, a survey of children less than five years of age was conducted in random clusters of Karachi, Pakistan in three high risk towns where a polio case was detected in 2011. Center point of the cluster was calculated by the application on the mobile. Data and location coordinates were collected through a mobile phone. This data was linked with an automated mHealth based monitoring system for monitoring of Supplementary Immunization Activities (SIAs) in Karachi. After each SIA, a visual report was generated according to the coordinates collected from the survey.Result: A total of 3535 participants consented to answer to a baseline survey. We found that the mobile phones incorporated with GIS maps can improve efficiency of health providers through real-time reporting and replacing paper based questionnaire for collection of data at household level. Visual maps generated from the data and geospatial analysis can also give a better assessment of the immunizationcoverage and polio vaccination campaigns.Conclusion: The study supports a model system in resource constrained settings that allows routine capture of individual level data through GPS enabled mobile phone providing actionable information and geospatial maps to local public health managers, policy makers and study staff monitoring immunization coverage

Effect of 5-minute movies shown via a mobile phone app on risk factors and mortality after stroke in a low- to middle-income country: Randomized controlled trial for the stroke caregiver dyad education intervention (Movies4Stroke)

Background: Pakistan is the sixth most populous nation in the world and has an estimated 4 million stroke survivors. Most survivors are taken care of by community-based caregivers, and there are no inpatient rehabilitation facilities.Objective: The objective of this study was to evaluate the effectiveness and safety of locally designed 5-min movies rolled out in order of relevance that are thematically delivered in a 3-month program to deliver poststroke education to stroke survivor and caregiver dyads returning to the community.Methods: This study was a randomized controlled, outcome assessor–blinded, parallel group, single-center superiority trial in which participants (stroke survivor-caregiver dyads) with first-ever stroke (both ischemic and hemorrhagic) incidence were randomized within 48 hours of their stroke into either the video-based education intervention group or the control group. The video-based education intervention group had health education delivered through short videos that were shown to the participants and their caregivers at the time of admission, before discharge, and the first and third months of follow-up after discharge. The control group had standardized care including predischarge education and counseling according to defined protocols. All participants enrolled in the video education intervention and control groups were followed for 12 months after discharge for outcome assessment in the outpatient stroke clinics. The primary outcome measures were the proportion of participants achieving control of blood pressure, blood sugar, and blood cholesterol in the video intervention versus the control group. Several predefined secondary outcomes were included in this study, of which we report the mortality and functional disability in this paper. Analysis was by performed using the intention-to-treat principle.Results: A total of 310 stroke survivors and their caregiver dyads (participant dyads) were recruited over a duration of 6 months. In total, 155 participant dyads were randomized into the intervention and control groups, each. The primary outcome of control of three major risk factors revealed that at 12 months, there was a greater percentage of participants with a systolic BP(18/54, 33% vs 11/52, 21%; P=.16), diastolic BP(44/54, 81% vs 37/52, 71%; P=.21), HbA1c levelP=.32), and low-density lipoprotein level/dL (36/51, 70% vs 30/45, 67%; P=.68) in the intervention group than in the control group. The secondary outcome reported is the mortality among the stroke survivors because the number of stroke-related complications was higher in the control group than in the intervention group (13/155, 8.4% vs 2/155, 1.3%), and this difference was statistically significant (P\u3c.001).Conclusions: The Movies4Stroke trial failed to achieve its primary specified outcome. However, secondary outcomes that directly related to survival skills of stroke survivors demonstrated the effectiveness of the video-based intervention on improving stroke-related mortality and survival without disability

Adaptation and validation of recent life changes questionnaire (RLCQ) to measure stress among urban adult population of Karachi, Pakistan

Mental illnesses related to stress are increasing rapidly in our population. It is important to have reliable measures of stressful life events that are contextually relevant. The Recent Life Changes Questionnaire (RLCQ), developed by Richard Rahe in 1967, is one such tool that measures general stress with respect to life changing events but is not an accurate reflection of stressful life events in Pakistan since it has been developed for a first world setting. We aim to adapt RLCQ and validate the adapted RLCQ to allow accuracy in measurement of Stressful Life Events. Methods: The study was conducted in two phases: adaptation of the RLCQ and validation of the adapted RLCQ. In order to identify contextually relevant stressors in an open ended format, we used the qualitative method of in-depth interviews until saturation of reported events was received. These interviews were conducted from 20 purposefully selected residents of Karachi who visited general out-patient departments of Aga Khan University Hospital. Identified stressful events were included in the tool and those recognized as not stressful were removed. After identification of all relevant stressors, we performed the next phase of adaptation that required scaling of each item on the questionnaire so as to weigh each of these events in terms of severity of stress. This scaling exercise was performed on 200 random participants residing in four communities of Karachi namely Kharadar, Dhorajee, Gulshan and Garden. For analysis of the scaled tool, exploratory factor analysis was used to inform structuring. Content validity and face validity was also performed to complete the process of adaption by expert review, translation and back translation of the adapted RLCQ. In the second phase of the study, we performed validation of the resultant adapted RLCQ. 300 participants residing in the above four communities responded to the adapted RLCQ along with Mini International Neuropsychiatric Interview (MINI) which was our gold standard. ROC curves were generated and Sensitivities and Specificities of the adapted RLCQ for common mental disorders were reported. Cut offs were defined within the adapted and validated RLCQ for stressful life event measurements that were highly likely to correlate with the presence of neuropsychiatrically defined mental illness. Results: Stressful life events emerging from the qualitative phase of the study reflect daily life stressors arising from socio-political environment. Upon applying factor analysis, suggested categories were not meaningful; hence we kept the questionnaire in its original state and introduced a new category of \u27Environmental Stressors\u27. In comparison of adapted RLCQ with MINI, AUC of ROC curve for serious mental disorders (SMD) and common mental disorders (CMD) came out to be 0.75 and 0.65 respectively. The sensitivity and specificity for SMD is 72% and 60% and that of CMD is 66% and 56% respectively. Conclusion: The adapted and validated RLCQ defines relevant events with cut offs that are able to predict the likelihood of common and serious mental illnesses which would develop as a result of experiencing high levels of chronic stress in urban population of Karachi with a reasonable sensitivity and specificity

Sex-stratified outcomes of primary percutaneous coronary intervention: A tertiary care experience

Background: ST elevation myocardial infarction (STEMI) is an acute cardiac manifestation that requires immediate revascularization preferably through primary percutaneous coronary intervention (PCI). This study aims to describe gender stratified outcomes and epidemiological profile of STEMI patients undergoing treatment at a tertiary care hospital in Karachi, Pakistan.Methods: A 5-year, retrospective analysis of hospital records was undertaken on confirmed STEMI patients admitted between 2010 and 2014, undergoing primary PCI. Information was retrieved on demographic variables, risk factors, total ischemia time, door to balloon time, angiographic findings, and treatment strategy and in-hospital outcomes.Results: A total of 603 patients were available for analysis. Mean age of the participants was 58 ± 11 years, with 78.6% being males. The most common risk factors were hypertension (48.1%), diabetes (37%), and smoking (22.2%). Gender stratified analysis revealed poorer clinical presentation and prolonged ischemia time among women when compared to men (410 vs. 310 min, respectively). Total in-hospital mortality was 9.6% and was higher in women (19.3%), patients with non-anterior infarction (12%), Killip class \u3e2 (39%), advanced age (14.6%), and multi-vessel disease (12%).Conclusion: Our study describes the common risk factors and treatment outcomes for STEMI patients undergoing primary PCI at a tertiary care hospital in Karachi. In-hospital mortality and total ischemia time were higher among women compared to men in our study. Moreover, the risk profile, treatment related complications, and outcomes were poorer in women compared to men. We suggest further research to investigate the effect of prolonged ischemia time on long-term clinical outcomes

Role of trans-radial band protocols in radial artery occlusion: Randomized trial

Background: Radial artery occlusion is a common complication of coronary angiography via radial artery, attributed to the prolonged use of trans-radial band post procedure. Literature suggests there is no standard protocol for radial band deflation, and it varies across institutions. However, the protocol suggested by Cohen and Alfonso is widely used globally. This study aims to test whether our hospital\u27s radial band deflation protocol is non-inferior to the protocol of Cohen and Alfonso, which affirms lesser complications.Methods: This is an outcome assessor blinded, non-inferiority trial conducted at a tertiary care hospital in Karachi. We enrolled 100 patients who underwent coronary angiography from radial access and gave written informed consent. The intervention group received protocol A, that is in practice at the institution, while the control group received protocol B, developed by Cohen and Alfonso. The primary outcome was occurrence of radial artery occlusion at 24 h. The secondary outcomes included hematoma and bleeding after radial band removal.Results: The mean age of the participants in the trial was 58.3 ± 11.5 years, while 63% of them were men. Participants in both the groups had similar baseline characteristics. Radial artery occlusion was not significantly different between protocol A and protocol B (10% vs. 14%, p = 0.49, respectively). Similarly, hematoma and bleeding after trans-radial band removal showed no statistical difference between the groups.Conclusion: Trans-radial band deflation practice at our institution was non-inferior to Cohen and Alfonso\u27s protocol in the incidence of radial artery occlusion after coronary angiography.Trial registration number: This trial is registered at clinicaltrials.gov (https://clinicaltrials.go