Pakistan Journal of Cardiovascular Intervention

Comparison of the clinical characteristics and in hospital outcomes of proximal versus non-proximal lesions in dominant right coronary artery ST-elevation myocardial Infarction

2024-06-29T06:26:09+00:00

Background: Right coronary artery (RCA) ST-elevation myocardial infarction (STEMI) is a critical cardiovascular condition that can lead to significant morbidity and mortality if not treated promptly. Primary percutaneous coronary intervention (PCI) is the gold standard for managing STEMI patients. The objective of this study is to evaluate clinical characteristics and outcome of proximal versus non-proximal, in dominant “right coronary artery (RCA) ST-elevation myocardial infarction (STEMI)” patients undergoing primary PCI at NICVD, Karachi.

Methodology: This retrospective comparative cross-sectional study included equal number of consecutive patients diagnosed with dominant “RCA STEMI” with culprit proximal and non-proximal lesions undergoing primary PCI. In-hospital clinical outcomes including mortality, heart failure, cardiogenic shock, ventricular arrhythmias, myocardial infarction, stent thrombosis, AV block, TPM placement, IABP placement, and other procedure-related complications were compared between the two groups.

Results: Total 355 patients each with proximal lesions and non-proximal lesions were included. Age was similar between the two groups, with no significant difference observed (56.9 ± 10.8 years vs. 56 ± 10.4 years; p = 0.367). Pre-procedure TIMI flow was significantly worse in the proximal lesion group compared to the non-proximal lesion group (TIMI 0: 70.1% vs. 66.8%; p = 0.015). Delay in PCI was noted for 107 (30.2%) vs. 68 (19.2%); p=0.001in proximal compared to the non-proximal group, respectively.

Conclusion: Proximal lesions appear to be associated with poorer initial coronary blood flow and a higher likelihood of in-hospital mortality. Further, a significant delay in intervention was observed for proximal group. Hence, these findings revealed the importance of timely intervention and tailored management strategies based on lesion location in optimizing outcomes for STEMI patients.

The severity of coronary artery disease in NSTEMI patients, as evaluated by the Syntax score, is investigated in relation to the TIMI risk score

2025-01-01T07:47:31+00:00

Background: Non-ST elevation myocardial infarction (NSTEMI) carries significant risks. The TIMI Risk Score for Nstemi and Syntax score are used to assess coronary artery disease severity, respectively. This study investigates the relationship between these two scores in NSTEMI patients to potentially refine treatment strategies and risk stratification.

Methodology: The Department of Cardiology carried out this descriptive cross-sectional research investigation in PIMS, Islamabad, Pakistan, included 297 NSTEMI patients who underwent coronary angiography between August 27, 2022, and February 26, 2023. The TIMI Risk Score (based on clinical variables) and Syntax Score (calculated using syntax.com) were determined for each patient. Data analysis, performed using SPSS Version 21, included descriptive statistics, Pearson correlation to assess the relationship between the scores, and stratified analysis to control for potential effect modifiers (age, gender, diabetes mellitus, hypertension, smoking status, BMI, and extent of coronary artery disease).

Results: The age range of the 297 NSTEMI patients (median 59) was 18 to 75 years old. There were 136 (45.8%) females and 161 (54.2%) males in the group. The TIMI Risk Score and the Syntax Score showed a weak positive correlation (r = 0.117, p = 0.0001), indicating a restricted relationship.

Conclusion: This study found a weak correlation among Syntax Score and the TIMI Risk Score in patients with NSTEMI. Further research is needed to confirm these findings and explore the implications for clinical practice.

Identification Of Risk Factors Influencing In-Stent Restenosis (ISR) In Post Percutaneous Coronary Intervention (PCI) Patients

2024-08-07T09:25:28+00:00

Background: To identify and analyze the risk factors influencing in-stent restenosis (ISR) in patients following percutaneous coronary intervention (PCI).

Methodology: A retrospective cross-sectional study was conducted at the Cardiology Unit of Hayat Abad Medical Complex, Peshawar, from February 2021 to September 2022. The study included 292 patients who had undergone PCI within the last six years and were currently presenting with symptoms of angina or acute coronary syndrome (ACS). Patients were divided into two groups based on coronary angiography findings: ISR Group (n=147) and Non-ISR Group (n=145). Data collection was performed using a pre-designed questionnaire, with subsequent clinical and laboratory examinations to identify potential ISR risk factors. Statistical analysis involved chi-square and t-tests for categorical and continuous variables, respectively, and multivariate logistic regression to adjust for confounders.

Results: Significant risk factors for ISR included diabetes mellitus (P=0.001), smoking (P=0.002), hypertension (P=0.003), and elevated LDL cholesterol levels (P=0.030). Stent-related factors such as longer stent length (>40mm) and smaller diameter (<2.75mm) also showed significant associations with ISR occurrence. The logistic regression analysis confirmed these factors as independent predictors of ISR.

Conclusion: The study highlights the importance of comprehensive risk factor management and careful procedural planning in reducing the incidence of ISR. Targeted interventions focusing on modifiable risk factors and optimizing stent selection and placement are crucial for improving long-term outcomes in patients undergoing PCI.

Residual Synergy between percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score to Predict in-hospital Clinical Outcomes among ST Elevation Myocardial Infarction Patients undergoing Primary Percutaneous Coronary Intervention

2024-10-02T06:06:48+00:00

Background: The SYNergy between Percutaneous Coronary Intervention (PCI) with TAXUS and Cardiac Surgery (SYNTAX) score (SS) assesses the anatomical complexity of Coronary Artery Disease (CAD). Residual SS (rSS) quantifies the burden of residual CAD following PCI.

Methodology: It was a descriptive cross-sectional study conducted at the Peshawar Institute of Cardiology inpatient departments, from March 2023 to Aug 2023. Patients, who satisfied the criteria for type 1 Myocardial Infarction (MI), were included in the study by non-probability consecutive sampling technique. Baseline SS (bSS) and rSS were calculated using an online calculator (syntax.org/calculator) Patients were stratified as Complete Revascularization (CR) rSS =0, Reasonably Incomplete Revascularization (RICR) rSS >0 and ≤8, and Incomplete Revascularization (ICR) rSS >8. In-hospital clinical outcomes included all causes in-hospital mortality and Major Adverse Cardiac and Cerebrovascular Events (MACCE) were recorded. The analyses were conducted using the statistics and data analysis (STATA) version 14.2.

Results: A total of 426 patients were included in our study. The most common risk factor for CAD was hypertension. In the ICR group, 21.4% of patients had Significant Left Main Stem disease. The majority of the CR subjects had significant single-vessel CAD. In CR and RICR groups, the Left Anterior Descending artery while in ICR Right Coronary Artery was the common culprit vessel causing MI. All-cause in-hospital mortality was 4.2% and MACCE was 11.03%, and were common among the ICR subjects (9.8% and 10.7%, respectively), but had a comparable proportion in CR and RICR groups. Logistic regression revealed a significant association between rSS categories and mortality, (Odds ratio 2.42; 95% CI: 1.28 to 4.57).

Conclusion: The rSS is a useful tool in quantifying incomplete revascularization among STEMI patients undergoing primary PCI, and ICR appears to confer a higher in-hospital mortality and MACCE.

Clinical Profile and Outcome in Patients with Acute Coronary Syndrome (ACS) with Left Main Disease Presenting at Tertiary Care Hospital Karachi, Pakistan

2024-11-22T07:40:34+00:00

Background: Left main coronary artery disease (LMCAD) in acute coronary syndrome (ACS) poses significant concerns due to its vital role in myocardial perfusion. A blockage in this artery can precipitate a severe and potentially fatal heart attack. This study aimed to evaluate the clinical profile and outcomes of ACS patients with LMCAD presenting at a tertiary care hospital in Karachi, Pakistan.

Methodology: This cross-sectional study enrolled consecutive ACS patients with LMCAD, defined as 50% or more stenosis in the left main coronary based on coronary angiography. We assessed the clinical characteristics and in-hospital outcomes of these patients.

Results: Among 236 ACS patients with LMCAD, predominantly male (69.1%) with a mean age of 58.8 ± 9.3 years, most presented with three-vessel disease. Common comorbidities included hypertension (65.3%) and diabetes mellitus (47.9%). Complications, such as contrast-induced nephropathy (13.1%) and major bleeding (2.5%), affected 19.5% of patients, with an in-hospital mortality rate of 4.2%.

Conclusion: The in-hospital mortality rate of 4.2% underscores the grave implications of LMCAD in ACS. The predominance of three-vessel disease highlights its severity and complexity. Complications like contrast-induced nephropathy and major bleeding further accentuate the challenges in managing these cases.

Pattern of TIMI Flow in Late Arrival STEMI its impact on mortality and Factors that Predict the TIMI ≥ II in Patients with Late Arrival Pattern of TIMI

2024-11-19T06:42:23+00:00

Background: Acute ST Elevation Myocardial Infarction has high mortality but timely reperfusion is related to improved LV function and improved mortality. Clinical trials demonstrated decreased infarct size and improved mortality in late-arrival STEMI patients. However a significant number of these late arrival patients had TIMI flow ≥II at the baseline. We performed a study to observe the prevalence of Pre-procedure TIMI ≥II flow, its predictors and its impact on In-hospital mortality.

Methodology: It was a two-center observational study conducted at the National Institute of Cardiovascular Disease and its satellite from November 2022 to September 2023. Late-arrival STEMI patients who presented >12 hours after symptoms onset and had undergone cardiac catheterization were included. The baseline TIMI flow in the culprit artery was noted. The patients were followed until discharge.

Results: A total of 305 patients were included in the study. Hypertension was the most prevalent risk factor in 50% (153) followed by diabetes in 34% (104). The prevalence of TIMI ≥II flow was present in 24.6% (75). There was no significant difference for in-hospital mortality between patients with baseline TIMI-0/I or Baseline TIMI-≥II at baseline (7.0% vs. 6.7%). The presence of chest pain within 24 hours (OR: 2.2), and Killip class-II (OR: 2.99) at arrival were predictors associated with TIMI ≥II at baseline angiogram.

Conclusion: Chest pain within 24 hours and killip class-II at presentation were associated with open artery at baseline on angiogram. These factors may be considered for beneficial effect while choosing patients with late arrival STEMI for revascularization.

A Needle in a Haystack: uncovering RV branch compromise after primary PCI of RCA via ECG

2024-06-29T16:10:54+00:00

Background: ECG remains the mainstay of diagnosis of STEMI in clinical practice and proper interpretation helps to identify the culprit artery. We present a rare case in which ST elevation in ECG proved to be quite misleading.

Case Presentation: We present the case of an elderly male patient who presented to emergency department with acute onset of severe chest pain. Ecg done in emergency department which showed inferior wall myocardial infarction (MI) complicated by complete heart block. He underwent angioplasty of right coronary artery. Patient in CCU developed ST elevation in anterior chest leads which was attributed to RV branch occlusion.

Management and Results: Patient was managed medically as he was pain free and hemodynamically stable. Serial ECG’s done. He was strictly monitored in CCU for any hemodynamic or electrical instability. Patient remained pain free throughout his stay in CCU. After 6 to 8 hours ST segment elevation completely settled down with no Q wave formation.

Conclusion: ST segment elevation in anterior leads is hallmark of anterior wall MI. Interestingly, isolated right ventricle MI can also produce similar changes in ECG. Very few case reports found on management of isolated RV branch occlusion and patient can present with a wide spectrum of clinical presentation from being completely asymptomatic to suffering from cardiac arrest. Management of isolated RV branch occlusion is another dilemma and it can vary from case to case.

Successful Treatment of an Under Expanded Stent using Rotational Atherectomy: First Reported Case of Stent Ablation From Pakistan

2024-10-04T10:24:40+00:00

Background: Patients with under expanded coronary stents due to coronary artery calcification are at an increased risk of cardiovascular morbidity and mortality. Importantly, these present a challenging subset patients undergoing percutaneous coronary intervention. Rotational atherectomy is a time-tested technique to treat coronary artery calcification. However, its utilitization in treating under expanded coronary stents due to coronary artery calcification remains fraught with uncertainty amid the perceived risk of complications.

Case Presentation: We present the case of an 80-year old patient with a previously deployed under expanded coronary stent in his right coronary artery who presented with an acute coronary syndrome to our institute. Coronary angiography revealed severe instent restenosis and the lesion proved to be non-dilatable.

Management and Results: This patient underwent successful rotational atherectomy with a 1.75 mm burr at 160,000 revolutions per minute (rpm) to treat the severe instent restenosis and underexpanded stent (stent ablation) with satisfactory subsequent lesion dilatation followed by another drug eluting stent implantation.

Conclusion: Rotablation remains a viable option to treat under expanded stents as well as non-dilatable in stent restenosis. However, care must be exercised using this technique to avoid the risk of burr entrapment while treating under expanded stents.