Pakistan Journal of Cardiovascular Intervention

Gender Disparities in Management and Outcomes of STEMI Patients Undergoing Primary PCI: A Single-Center Experience.

Sun, 01 Jun 2025 00:00:00 +0000

Background: Gender-based differences in the clinical presentation, angiographic findings, and outcomes of ST-elevation myocardial infarction (STEMI) are increasingly recognized worldwide. However, region-specific data, especially from South Asian cardiac centres, remain limited. To evaluate gender-based differences in angiographic characteristics, procedural interventions, and in-hospital outcomes among STEMI patients undergoing primary percutaneous coronary intervention (PCI) at a tertiary cardiac centre.

Methodology: This retrospective study included 257 STEMI patients (194 males, 63 females) admitted between March and August 2024. Upon admission, all patients underwent diagnostic workup including ECG, troponin, myocardial enzymes, and other biochemical markers, followed by primary PCI. Comparative analysis was performed between male and female patients regarding baseline risk factors, angiographic patterns, procedural characteristics, and in-hospital adverse events.

Results: The mean age of male patients was 57.84 ± 10.83 years and female patients 59.31 ± 12.06 years. Smoking was reported only in males (14.43% vs. 0%), whereas females had significantly higher rates of hypertension (76.19% vs. 42.27%), diabetes mellitus (58.73% vs. 23.71%), and heart failure (20.63% vs. 10.31%). Anterior wall myocardial infarction (AWMI) was predominant among males, while inferior wall myocardial infarction (IWMI) was more common in females. The left anterior descending (LAD) artery was identified as the most frequent culprit vessel in both sexes. No significant differences were observed in procedural parameters; however, catheterization lab-related complications (p = 0.05) and in-hospital major adverse cardiac events (MACE) (p = 0.035) were significantly higher in female patients.

Conclusion: Female patients with STEMI present with a greater burden of cardiovascular comorbidities and experience higher in-hospital complication rates and MACE following primary PCI, despite a similar age of onset and angiographic profiles to their male counterparts. These findings underscore the importance of sex-specific risk stratification and post-PCI monitoring to improve outcomes in women.

Postoperative Complications Following Total Surgical Correction of Tetralogy of Fallot: A Retrospective Cross-Sectional Study.

Sun, 01 Jun 2025 00:00:00 +0000

Background: Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart defect. Total surgical correction remains the definitive treatment. Despite improvements in surgical techniques, postoperative complications are still reported and vary in severity. Understanding these complications is crucial for improving surgical outcomes and postoperative care. To determine the frequency and types of in-hospital postoperative complications following total surgical correction of Tetralogy of Fallot.

Methodology: This retrospective cross-sectional study was conducted at the Department of Cardiovascular Surgery, Lady Reading Hospital, Peshawar, from January 2010 to December 2020. A total of 150 patients who underwent complete surgical correction for TOF were included using non-probability consecutive sampling. Patients aged 3 to 25 years of both genders were enrolled. Data were collected from hospital records and analyzed using SPSS version 20.

Results: A total of 150 patients were included, with a mean age of 6.5 ± 2.9 years (range: 3–25 years). Males constituted 60% (n = 90) of the study population. Isolated TOF was present in 55% of the patients, while 45% had associated anomalies, such as patent foramen ovale (PFO), atrial septal defect (ASD), patent ductus arteriosus (PDA), right-sided aortic arch, and left superior vena cava (SVC). The most frequently observed postoperative complications included heart failure (12%), postoperative bleeding, and conduction abnormalities. Complete heart block, the most common conduction disturbance, was observed in 5 cases (3.3%). Pleural effusion and pneumothorax were also documented but occurred less frequently.

Conclusion: Postoperative complications following total correction of Tetralogy of Fallot are not uncommon. The most frequently observed complications in this study were bleeding, heart failure, complete heart block, and pneumothorax. Early identification and management of these complications are essential to improving patient outcomes.

Diagnostic Accuracy of D-Dimers in Patients with Non-ST-Segment Elevation Myocardial Infarction Using Troponin-I as the Gold Standard.

Qazi Najeeb Ullah Amin, Muhammad Abdur Rauf, Dawood Khan, Arshad — Sun, 01 Jun 2025 00:00:00 +0000

Background: Non-ST segment elevation myocardial infarction (NSTEMI) is defined as a clinical syndrome characterized by symptoms of myocardial ischemia and the release of biomarkers of myocardial necrosis in the absence of electrocardiographic ST-segment elevation. Biomarkers play a pivotal role in both the early diagnosis and prognosis of myocardial infarction. Among them, D-dimer has been proposed as a potential diagnostic marker. This study aimed to determine the diagnostic accuracy of D-dimer in patients with NSTEMI, using Troponin-I as the gold standard.

Methodology: Following approval from the College of Physicians and Surgeons Pakistan (CPSP), a cross-sectional validation study was conducted in the Department of Cardiology, Hayatabad Medical Complex, Peshawar, from March 7 to September 7, 2019. Patients aged 18 to 80 years presenting with suspected NSTEMI were enrolled after providing written informed consent. Each participant underwent a detailed history, physical examination, and 12-lead electrocardiography (ECG). Troponin-I was measured prior to administration of anticoagulant therapy in the emergency department, while D-dimer was tested concurrently. Diagnostic accuracy was assessed using Troponin-I as the reference standard.

Results: A total of 275 patients were included, of whom 69.81% were male. The mean age was 62 ± 10.79 years. The majority of patients were non-smokers (81.45%), non-diabetic (86.55%), and normotensive (86.55%). When compared with Troponin-I, D-dimer showed a sensitivity of 38.68%, specificity of 47.38%, positive predictive value (PPV) of 14.91%, negative predictive value (NPV) of 76.36%, and an overall diagnostic accuracy of 45.64%.

Conclusion: Although D-dimer alone demonstrated limited sensitivity and specificity, its relatively high negative predictive value suggests potential utility as a supportive biomarker in ruling out NSTEMI. Incorporating D-dimer testing into the routine chest pain unit protocol, alongside established biomarkers such as Troponin-I, may aid in early risk stratification and clinical decision-making.

Clinical and demographic characteristics of patients with Coronary Artery Disease: Insights from a single-center study.

Syed Muzammil Shah, Tariq Shah, Kashif Ali Khan, Tariq Rahim, Afrasiyab Kundi — Sun, 01 Jun 2025 00:00:00 +0000

Background: Coronary artery disease (CAD) is the leading cause of morbidity and mortality in Pakistan, with chronic total occlusion (CTO) representing an advanced and challenging manifestation. Understanding the demographic, clinical, and angiographic profiles of affected patients is essential for improving management and prevention strategies. This study aimed to investigate the demographic, clinical, and angiographic characteristics of patients with CAD and CTO presenting to a tertiary cardiac center in Pakistan.

Methodology: A prospective observational study was conducted in the Department of Cardiology, Lady Reading Hospital, Peshawar, between February 2024 – January 2025. Adult patients (≥18 years) with angiographically confirmed CAD and CTO were enrolled. Data on demographics, cardiovascular risk factors, clinical presentations, and angiographic features were collected using a structured proforma and analyzed with SPSS v26.

Results: Among 117 patients, 73.5% were male, and the majority were older than 50 years. Hypertension (66.7%), diabetes mellitus (53.8%), and tobacco use (38.5%) were the most prevalent risk factors. Multivessel involvement was common, with unstable angina and NSTEMI as the dominant presentations. The right coronary artery was most frequently affected (52.1%). Age stratification revealed a higher burden of hypertension and multivessel CAD in older patients.

Conclusion: CAD with CTO in Pakistan predominantly affects older men and is strongly associated with hypertension, diabetes, and tobacco use. The high prevalence of multivessel disease and advanced clinical presentation highlights the urgent need for targeted preventive measures, early screening, and equitable access to cardiovascular care.

Lived experiences and cardiovascular perceptions of E-Cigarette users in Peshawar, Pakistan: A Phenomenological Exploration.

Sun, 01 Jun 2025 00:00:00 +0000

Background: The rapid rise in electronic cigarette (e-cigarette) use in Pakistan, particularly in urban centers such as Peshawar, has generated increasing concern regarding potential cardiovascular risks. While e-cigarettes are promoted as a harm-reduction tool for smokers, their long-term cardioprotective or cardiotoxic effects remain unclear, especially within South Asian populations. Understanding how users interpret these risks is essential for guiding public health action. The aim was to explore the lived experiences, perceptions, and cardiovascular health concerns of adult e-cigarette users in Peshawar, Pakistan.

Methodology: A qualitative phenomenological design was employed. Twelve adult e-cigarette users were purposively selected and interviewed using semi-structured interviews conducted in the local language. Audio-recorded interviews were transcribed verbatim and analyzed using Braun and Clarke’s six-phase thematic analysis framework.

Results: Five key themes emerged: (1) perceived harm-reduction and control, (2) awareness and experiential physical changes, (3) ambivalence toward cardiovascular symptoms, (4) social acceptance and normalization of vaping, and (5) uncertainty and the need for credible information. Although many participants reported improved breathing or stamina, several simultaneously described symptoms such as palpitations or chest discomfort. A statistically significant association was found between cardiovascular symptoms and perceived physical improvement, indicating that users without symptoms were more likely to feel physically better.

Conclusion: Participants generally viewed vaping as a safer alternative to smoking but remained uncertain about its long-term cardiovascular effects. The coexistence of perceived benefits and emerging symptoms highlights the need for clearer clinical guidance and locally relevant health education.

Complex PCI without Surgical on Site Set up! Is it safe?

Syed Tahir Shah, Muhammad Hafizullah, Jabar Ali — Sun, 01 Jun 2025 00:00:00 +0000

Coronary Percutaneous intervention (PCI) has evolved over last 3 to 4 decades and it is now considered safe and effective treatment option for patients with coronary artery disease (CAD) across the globe. Advancement in devices, drugs and technology used for PCI have changed the horizon of interventional cardiology procedures from simple PCI to complex PCI with variable set of lesions such as chronic total occlusions (CTOs), heavily calcified and unprotected left main disease demonstrating high rate of procedural success and safety. Despite this improvement in PCI, the surgery on site (SOS) is mandated on the notion of safety paradigm.

Coronary Artery Dominance and Myocardial Infarction: A Review of Anatomical Variations, Physiological Impacts, and Clinical Implications in Inferior Myocardial Infarction.

Affan Salim Adnan, Mohammad Ibrahim Khan, Abdul Moiz Qureshi — Sun, 01 Jun 2025 00:00:00 +0000

Background: Coronary artery dominance defined by the vessel supplying the posterior descending artery (PDA) plays a critical role in the prognosis and management of myocardial infarction. While right dominance is the most common anatomical pattern, left dominance is associated with a higher risk of adverse outcomes, particularly in inferior wall myocardial infarctions (MI).

Methodology: This narrative literature review was conducted using scientific databases including PubMed, NCBI, Google Scholar, as well as publisher platforms such as ScienceDirect and SpringerLink. Peer-reviewed English-language articles published from 1940 to 2025 were reviewed. Foundational anatomical concepts were supplemented by standard anatomical textbooks. Clinical relevance was ensured by synthesizing literature based on pre-formulated research questions.

Results: Right coronary dominance is present in approximately 75% of individuals, while left and co-dominant patterns account for the remainder. Right and co-dominance are generally associated with better anatomical and clinical outcomes due to more robust collateral circulation. In contrast, left dominance is linked to an increased risk of ischemia in inferior wall MIs due to insufficient perfusion to the PDA territory. Although coronary flow reserve may be influenced by dominance type, this remains an underexplored area. Clinical outcomes can be improved by aligning ECG findings with coronary anatomy and tailoring surgical or interventional strategies accordingly. Routine documentation and confirmation of coronary dominance either incidentally or deliberately via imaging can aid clinical decision-making.

Conclusion: Coronary artery dominance is a critical anatomical and physiological factor that significantly influences outcomes in inferior STEMI. Integrating coronary dominance assessment into diagnostic and treatment protocols using ECG, angiography, and emerging tools such as AI can help personalize patient management, reduce complications, and improve prognosis. Future research should focus on quantifying the physiological effects of dominance types and optimizing therapeutic strategies accordingly.

Successful Retrieval of a Stalled Rotational Atherectomy Burr.

Omar Rana, Hamza Ali Khan, Mudassar Hanif Khokhar — Sun, 01 Jun 2025 00:00:00 +0000

Background: Rotational atherectomy (Rotablation, RA) is a well-established and time-tested technique to treat calcified coronary arteries through plaque modification. This can be achieved by using Rota burrs of different sizes revolving at speeds in excess of 150,000 revolutions per minute (rpm). A stalled burr is perhaps the most feared complication of this technique.

Case Presentation: We present the case of a 63-year old patient who presented with unstable angina. His right coronary artery was severely calcified with two severe discrete stenosis in the proximal and distal vessel respectively. The left coronary vessels were unobstructed.

Results: We elected to perform up-front RA using a 1.25 mm burr at 180,000 rpm. However, after the first pass across the proximal lesion, the burr came to an abrupt halt. Initially, the burr was pulled manually which proved futile. We then cut the burr shaft and rota wire simultaneously near the advancer hub and stripped off the outer plastic coating. Subsequently, another wire was introduced into the same guide catheter and a 2.0 x 15 mm balloon was inflated across the stalled burr which was successfully released and retrieved. The case was successfully completed with the implantation of two drug eluting stents.

Conclusion: We have described a case report of a stalled burr which was retrieved through the same guide catheter by cutting through and stripping off the outer coating of a burr shaft. To the best of our knowledge, we believe this to be the first described case report from Pakistan describing this novel technique to successfully retrieve a stalled burr percutaneously.

Starting Small: A Case Report on the First Percutaneous PDA Closure in a Preterm Neonate in Khyber Pakhtunkhwa.

Saadia Ilyas, Zaland Ahmed Yousafzai, Qazi Kamran Amin, Dil Nawaz Shah — Sun, 01 Jun 2025 00:00:00 +0000

Background: Patent ductus arteriosus (PDA) is a common cardiovascular condition in preterm infants, particularly those with extremely low birth weight (ELBW). If left untreated, a hemodynamically significant PDA (hsPDA) can lead to serious complications such as heart failure, respiratory distress, and poor weight gain. The Amplatzer Piccolo Occluder offers a minimally invasive transcatheter alternative to surgical ligation for infants weighing ≥700 g, reducing procedural risks and improving clinical outcomes.

Case Presentation: We report the case of a female infant born at 32 weeks of gestation with a birth weight of 1.2 kg, who developed symptoms of congestive heart failure, feeding difficulties, and failure to thrive. Echocardiography confirmed a hemodynamically significant PDA unresponsive to pharmacologic management. The infant was referred for transcatheter PDA closure.

Management and Results: A percutaneous closure was successfully performed on the 29th day of life using a 5×4 mm Amplatzer Piccolo Occluder via the femoral approach. The procedure was guided by fluoroscopy and echocardiography and conducted without the use of contrast due to impaired renal function. The intervention was uneventful, with no procedural complications. The infant was extubated on the sixth post-procedure day and exhibited significant clinical improvement, including adequate weight gain and resolution of apnea. At the one-month follow-up, the infant remained stable with no residual shunt or adverse effects.

Conclusion: This case highlights the safety, feasibility, and effectiveness of using the Amplatzer Piccolo Occluder for PDA closure in ELBW infants, even in resource-limited settings. To the best of our knowledge, this represents the first reported use of the device in Pakistan and at our institution, marking a significant advancement in neonatal cardiac care.

The Havoc of Statins: A Case of Statin-Induced Rhabdomyolysis Following Rescue PCI to the Right Coronary Artery.

Sun, 01 Jun 2025 00:00:00 +0000

Background: Rhabdomyolysis is a potentially life-threatening condition characterized by skeletal muscle injury leading to the release of intracellular components such as creatine kinase (CK), myoglobin, and electrolytes into the systemic circulation. Statins remain one of the most common pharmacologic causes, particularly when precipitating factors such as high-dose therapy, sepsis, dehydration, or shock coexist. Early recognition and prompt intervention are crucial to avoid complications such as acute kidney injury (AKI), metabolic derangements, and arrhythmias.

Case Presentation: A 56-year-old woman with poorly controlled diabetes and hypertension presented with acute inferior wall myocardial infarction (IWMI). She received fibrinolysis followed by rescue percutaneous coronary intervention (PCI) to the right coronary artery (RCA). Post-procedure, she developed atrial fibrillation, hemodynamic instability, and sepsis, for which she received high-dose statin therapy as part of post-MI management. Within 48 hours, she developed dark urine, rising creatinine, markedly elevated CK levels (6,458 U/L), and declining urine output. Laboratory evaluation confirmed rhabdomyolysis, likely precipitated by statins in the context of sepsis and shock. Statins were discontinued, aggressive IV hydration was initiated, and antibiotics were started for hospital-acquired infection.

Results: Using the McMahon Score, the patient had a high-risk score of 7, indicating a significant likelihood of requiring dialysis. With early recognition, meticulous fluid resuscitation, hemodynamic support, and infection control, her renal function gradually improved without requiring renal replacement therapy. By discharge, her hemodynamics stabilized, urine output normalized, and creatinine levels began trending downward. At the one-week follow-up, renal function had completely recovered, cardiac rhythm normalized, and she remained clinically stable.

Conclusion: This case highlights the importance of recognizing statin-induced rhabdomyolysis in high-risk cardiovascular patients, particularly when interacting factors such as sepsis, dehydration, and hemodynamic compromise coexist. Careful monitoring of renal function and CK levels, early discontinuation of statins, and prompt supportive therapy remain critical to preventing morbidity and facilitating full recovery.