Objectives: Discharge/Left Against Medical Advice (AMA) is associated with worse outcomes in terms of MACE. There are no descriptions of ACS patients who left AMA in our nation cohorts. The aims of this study is to determine MACE in patients signing DAMA/LAMA and quantifying factors associated with LAMA in ACS patients in our population.
Methodology: An Ambi directional cohort study conducted on a total of n=257 patients from Jan 2014 to Dec 2018 who left AMA from a tertiary care hospital. Background data was collected from hospital electronic database and then patients/attendants were contacted through telephonic calls and email for follow up. Primary and secondary end points were to determine MACE and quantify factors associated with discharge AMA respectively.
Results: A total of n=346 patients signed discharge AMA from Jan 2014 to Dec 2018 out of which n=257 were successfully contacted and shared data after informed verbal consents. Out of 257, 63%(n=163) were men and 36.57%(n=94) were female. Hypertension was the common risk factor in both genders 80%(n=205) followed by DM and family history of premature coronary artery disease. Most common mode of presentation was NSTEMI followed by unstable angina and STEMI. Most common reason of LAMA was financial constraints in 43.1%(n=111) followed by treatment preferences in another setup and code DNR (don’t resuscitate). 22.57% patients belonged to low socioeconomic status. Total mortality till date of follow up was 60.7% (n=156) with One-year mortality of 78.8% (n=123) and 1st week mortality after LAMA was 15.18% (n=39). About 35.40% (n=91) of patient left to home and had mortality of 41%(n=64) and 64.56% (n=166) left for another hospital and had mortality of 58.97% (n=92). Those who survived had prevalence of recurrent MI and heart failure of 76% and 49% respectively on follow up.
Conclusion: Discharge against medical advice in ACS patients is associated with higher mortality. We need to educate our patients/attendant regarding disease severity, need of timely interventions and prognosis to decrease frequency of discharge AMA and minimize mortality.
Sinus node (SN) dysfunction is a common clinical condition. When the sinus node fails, there are subsidiary atrial pacemakers (SAP) that can take over as the leading pacemaker. In the goat heart, we compared the structures of the SAP and SN.
Methods
Adult female goats (n = 8) underwent either epicardial SN ablation (n = 4) sufficient to cause a ~50% fall in the heart rate or had a sham operation (n = 4). The site of earliest activation in these hearts was localised after 4 weeks using in vivo epicardial mapping technique. Preparations of SN (n = 4) and SAP (n = 4) were harvested and frozen, serially sectioned and stained for histology (Masson’s trichrome) and immunolabelled for connexin43 (Cx43; major connexin in the working myocardium; negative marker for nodal cells) HCN4 (main pacemaker channel; positive marker of nodal cells) and Sodium-Calcium Exchanger (NCX1; major ion-channel of the "calcium-clock"). Images were taken with light and confocal microscopy. The extent and morphology of the SN and SAP were determined. Comparative analysis of Cx43, HCN4 and NCX1 protein expression in the SN, SAP and atrial myocardium (AM) was performed.
Results
In control goats, earliest activation was in the SN, whereas after SN ablation earliest activation was in the SAP. The SN was located in the intercaval region parallel to the crista terminalis (CT) and extended half of its length in the long axis towards the inferior vena cava (IVC). The centre of the SN occupied the full thickness of the intercaval region. The SN, as in other species, consisted of cells, which were small, lightly stained (compared to atrial myocytes) and embedded in a network of connective tissue. The SAP was located along the caudal part of the CT near the IVC. The morphology of the SAP was intermediate to nodal and atrial tissue and it contained a mixture of atrial and nodal cells. HCN4 and NCX1 expression was SN=SAP >AM (p < 0.05) whereas Cx43 expression was AM = SAP >SAN (p < 0.05).
Conclusions
The SAP in the goat is situated caudal to the SN and expresses in abundance both HCN4, and NCX1 the principal ion-channels of the "membrane" and "calcium-clock" respectively; allowing pacemaking function. Furthermore, its anatomical location and its mixture of atrial and nodal cells suggest it is similar to the ‘paranodal area’ recently described in the human. Because of the subsidiary pacemaker function of this region and its sinus node-like ion channel expression, it may provide a useful target for novel methods of ‘biological pacemaking’.
Objectives: Atrial high-rate episodes (AHRE) are associated with an increased risk of subclinical atrial fibrillation (SCAF) and can be identified in patients with cardiac implantable electronic devices (CIEDs). This first study from Pakistan aims to determine the incidence of AHREs and the characteristics of a Pakistani cohort with AHREs. Methodology: In this bicentric Cross-sectional study, there were 162 patients of more than 18 years with CIEDs presenting to the device clinics were enrolled. The AHREs cutoff was predefined and AHREs were documented if they last for >30 seconds. Patients with known atrial fibrillation were excluded. Results: Mean age of the patients was 64.69±11.64 years and men were of 62.3%. AHREs were found in 22 (13.6%) patients out of which 13(8%) lasted more than 5 minutes. Mean AHREs cutoff 182.27±20.93. Mean CHA₂DS₂-VASc score; 3.10±1.47. 54.9% on beta-blockers, and 37% on angiotensin receptor blockers (ARB). Dual-chamber pacemaker (75.3%) and AV block (60.5%) mostly complete AV block , were the most common CIED and indication for an implant respectively. 43.8% had mildly dilated LA, only 1.2 % had severe mitral stenosis, and 3.1% had severe mitral regurgitation. Multivariable binary logistic regression analysis showed that patients on ARB had fewer episodes of AHREs (OR=0.2, 95% CI= 0.05 -0.8, P-value =0.023) while positive family history for coronary artery disease (CAD) was associated with more episodes (OR=5.62, 95% CI=1.58 -20, P-value =0.008). Conclusion: The incidence of AHREs was considerably lower in our population on CIEDs interrogation as compared to prior studies, although the CHA₂DS₂-VASc score is higher. ARB use and positive family history of CAD had a statistically significant association with AHRE occurrence.
Objectives: Intralesional coronary artery calcification (CAC) is an important prognostic marker in terms of target lesion failure, target vessel revascularization and clinical outcomes. Intravascular ultrasound (IVUS) plays a pivotal role in the optimal management of calcified coronary arteries. We aimed to determine the clinical outcomes of IVUS guided intervention of calcified coronary lesions in a South Asian country.
Methodology: We retrospectively studied a total of 134 consecutive patients, who underwent IVUS guided assessment of coronary arteries from January 2013 to March 2020 at a single center. Patients were categorized into two groups: those with coronary artery calcification (CAC, n=77) and without coronary artery calcification (non-CAC, n=57). The mean duration of follow-up was 40.3 ± 30.1 months. The two groups were compared based on their clinical characteristics, management, in-hospital events, follow-up, and major adverse cardiac events (MACEs) that included cardiovascular death, non-fatal MI, life-threatening arrhythmia, bleeding, heart failure, stroke, and target vessel revascularization.
Results: A total of 134 patients were included who had undergone IVUS and were divided into two groups patients with CAC (n=77) and non-CAC (n=57). Majority of the patients were male (n=97 [72.3%]), the mean age at presentation was 63.1 ± 12.9 years. In CAC group the most common risk factor was Age of the patient then dyslipidemia (n=68[88%] followed by 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=value 0.005), significant number of prior stent-ISR (n=27[47%]) p=0.024. Having CAC is associated with higher MACE (17 out of 26 events).
Conclusion: Patients with CAC have more comorbidities and more commonly present with acute coronary syndrome. MACEs were recorded higher in the CAC group although the results are not statistically significant.
Rastelli surgery is used for the correction of several CHDs. Although late-onset cardiac arrhythmias have emerged as a major complication after corrective surgeries, there is a paucity of data on arrhythmias after Rastelli surgery.
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