The incidental episode of ventricular fibrillation: a case report

Polymorphic ventricular tachycardia and ventricular fibrillation (VF) carry important prognostic implications, especially in the post myocardial infarction period. However, artifact on the electrocardiographic tracing can mimic VF particularly on routinely recorded rhythm strips in hospitals. Such misinterpretation can lead to expensive (and potentially risky) diagnostic and therapeutic steps. We report on such a case and highlight the need for careful inspection of the tracing

Prosthetic valve thrombosis despite seemingly-adequate anticoagulation: the dangers of transient lapses in anticoagulation

We report a 19-year-old woman with thrombosis of a prosthetic mitral valve that was most likely due to a short dip in anticoagulation in the days preceding the event. Interestingly, at presentation the Patient was super-therapeutic, most likely a result of hepatic congestion as the heart began to fail, creating an illusion of thrombosis despite adequate anti coagulation

Prognosis of hospitalized new-onset systolic heart failure in Indo-Asians--a lethal problem

Background: Systolic heart failure (SHF), particularly when requiring hospital admission carries a poor prognosis. There is a paucity of data in Indo-Asians on outcomes of SHF, among whom the burden of cardiovascular disease is consistently rising. The purpose of this study was to determine the frequency and predictors of mortality and morbidity amongst patients admitted with new-onset SHF at a tertiary care hospital in Pakistan. Methods and Results: Hospital charts of 196 patients with a diagnosis of new or recent onset (!3 months) SHF (ejection fraction [EF] !40%) were reviewed. Patients who died during the admission, those with life-limiting concomitant disease, and those without follow-up were excluded. Survival was calculated according to the Kaplan-Meier method. Hazards ratios (HR) and 95% confidence intervals (CI) were calculated using Cox’s regression model. Mean age (SD) was 61 (12.8) years. Majority (77%) had a prior ischemic heart disease. Mean EF (SD) was 25% (8.7). Median follow-up period was 379 days. Fifty-four (27.5%) patients died (at least 12 [22.2%] sudden deaths) and 102 (52%) experienced combined event of death or repeat hospitalization for SHF. Factors independently associated with death included (HR [95% CI]), serum sodium (0.94 [0.90e0.97]), admission pulse (1.02 [1.01e1.04]), systolic blood pressure (0.98 [0.97e0.99]), and severe mitral regurgitation (1.90 [1.03e3.48]). Conclusions: Admission for new or recent onset SHF predicts a grave 1-year prognosis in Indo-Asians. Measures to prevent ischemic heart disease and its sequelae are essential because developing nations simply cannot afford to treat and manage heart failure

Knowledge of modifiable risk factors of heart disease among patients with acute myocardial infarction in Karachi, Pakistan: a cross sectional study

BACKGROUND: Knowledge is an important pre-requisite for implementing both primary as well as secondary preventive strategies for cardiovascular disease (CVD). There are no estimates of the level of knowledge of risk factor of heart disease in patients with CVD. We estimated the level of knowledge of modifiable risk factors and determined the factors associated with good level of knowledge among patients presenting with their first acute myocardial infarction (AMI) in a tertiary care hospital in Karachi, Pakistan. METHODS: A hospital based cross-sectional study was conducted at the National Institute of Cardiovascular Disease, a major tertiary care hospital in Karachi Pakistan. Patients admitted with their first AMI were eligible to participate. Standard questionnaire was used to interview 720 subjects. Knowledge of four modifiable risk factors of heart disease: fatty food consumption, smoking, obesity and exercise were assessed. The participants knowing three out of four risk factors were regarded as having a good level of knowledge. A multiple logistic regression model was constructed to identify the determinants of good level of knowledge. RESULTS: The mean age (SD) was 54 (11.66) years. A mere 42% of our study population had a good level of knowledge. In multiple logistic regression analysis, independent predictors of "good" level of knowledge were (odds ratio [95% confidence interval]) more than ten years of schooling were 2.5 [1.30, 4.80] (verses no schooling at all) and nuclear family system (verses extended family system) 2.54 [1.65, 3.89]. In addition, Sindhi ethnicity OR [3.03], higher level of exercise OR [2.76] and non user of tobacco OR [2.53] were also predictors of good level of knowledge. CONCLUSION: Our findings highlight the lack of good level of knowledge of modifiable risk factors for heart disease among subjects admitted with AMI in Pakistan. There is urgent need for aggressive and targeted educational strategies in the Pakistani population

Survival of patients treated with intra-aortic balloon counterpulsation at a tertiary care center in Pakistan – patient characteristics and predictors of in-hospital mortality

BACKGROUND: Intra-aortic balloon counterpulsation (IABC) has an established role in the treatment of patients presenting with critical cardiac illnesses, including cardiogenic shock, refractory ischemia and for prophylaxis and treatment of complications of percutaneous coronary interventions (PCI). Patients requiring IABC represent a high-risk subset with an expected high mortality. There are virtually no data on usage patterns as well as outcomes of patients in the Indo-Pakistan subcontinent who require IABC. This is the first report on a sizeable experience with IABC from Pakistan. METHODS: Hospital charts of 95 patients (mean age 58.8 (± 10.4) years; 78.9% male) undergoing IABC between 2000–2002 were reviewed. Logistic regression was used to determine univariate and multivariate predictors of in-hospital mortality. RESULTS: The most frequent indications for IABC were cardiogenic shock (48.4%) and refractory ischemia (24.2%). Revascularization (surgical or PCI) was performed in 74 patients (77.9%). The overall in-hospital mortality rate was 34.7%. Univariate predictors of in-hospital mortality included (odds ratio [95% CI]) age (OR 1.06 [1.01–1.11] for every year increase in age); diabetes (OR 3.68 [1.51–8.92]) and cardiogenic shock at presentation (OR 4.85 [1.92–12.2]). Furthermore, prior CABG (OR 0.12 [0.04–0.34]), and in-hospital revascularization (OR 0.05 [0.01–0.189]) was protective against mortality. In the multivariate analysis, independent predictors of in-hospital mortality were age (OR 1.13 [1.05–1.22] for every year increase in age); diabetes (OR 6.35 [1.61–24.97]) and cardiogenic shock at presentation (OR 10.0 [2.33–42.95]). Again, revascularization during hospitalization (OR 0.02 [0.003–0.12]) conferred a protective effect. The overall complication rate was low (8.5%). CONCLUSIONS: Patients requiring IABC represent a high-risk group with substantial in-hospital mortality. Despite this high mortality, over two-thirds of patients do leave the hospital alive, suggesting that IABC is a feasible therapeutic device, even in a developing country

High prevalence of lack of knowledge of symptoms of acute myocardial infarction inPakistan and its contribution to delayed presentationto the hospital

<p>Abstract</p> <p>Background</p> <p>We conducted an observational study to determine the delay in presentation to hospital, and its associates among patients experiencing first Acute Myocardial Infarction (AMI) in Karachi, Pakistan.</p> <p>Methods</p> <p>A hospital based cross-sectional study was conducted at National Institute of Cardiovascular Disease (NICVD) in Karachi. A structured questionnaire was used to collect data. The primary outcome was delay in presentation, defined as a time interval of six or more hours from the onset of symptoms to presentation to hospital. Logistic regression analysis was performed to determine the factors associated with prehospital delay.</p> <p>Results</p> <p>A total of 720 subjects were interviewed; 22% were females. The mean age (SD) of the subjects was 54 (± 12) years. The mean (SE) and median (IQR) time to presentation was 12.3 (1.7) hours and 3.04 (6.0) hours respectively. About 34% of the subjects presented late. Lack of knowledge of any of the symptoms of heart attack (odds ratio (95% CI)) (1.82 (1.10, 2.99)), and mild chest pain (10.05 (6.50, 15.54)) were independently associated with prehospital delay.</p> <p>Conclusion</p> <p>Over one-third of patients with AMI in Pakistan present late to the hospital. Lack of knowledge of symptoms of heart attack, and low severity of chest pain were the main predictors of prehospital delay. Strategies to reduce delayed presentation in this population must focus on education about symptoms of heart attack.</p

Preoperative use of intra-aortic balloon counterpulsation in very high-risk patients prior to urgent noncardiac surgery

The optimal management of high-risk patients requiring urgent or emergency noncardiac surgery when the options for further testing and evaluation are limited, is unclear. The focus of most of the literature, including the American College of Cardiology/American Heart Association guidelines, has been on patients undergoing elective as opposed to urgent surgery. A few reports have suggested the use of intra-aortic balloon counterpulsation as a strategy to help carry such patients through the procedure. We describe three such very high-risk patients who successfully underwent emergency surgery with prophylactic insertion of an intra-aortic balloon pump without any adverse cardiac events or device-related complications. Our experience, as well as that of others suggests that preoperative intra-aortic balloon counterpulsation is a useful (and safe) approach to help very high-risk patients undergo urgent and emergency noncardiac surgery. Randomized trials are needed to assess whether balloon counterpulsation offers an incremental benefit over aggressive preoperative beta blockade