Extremely Late Stent Thrombosis in a First Generation Drug- Eluting Stent 10 Years After Stent Deployment: A Case Report

Stent thrombosis is one of the gravest complications of percutaneous coronary intervention which usually manifest as ST-segment elevation myocardial infarction or sudden death. There are a very few case reports in the literature regarding extremely late stent thrombosis in a drug-eluting stent. Here we report a case of extremely late stent thrombosis in a first generation drug-eluting stent in a 54 year old gentleman. To the best of our knowledge, this is the first case report with the longest duration (10 years) after sirolimus eluting first-generation DES in Bangladesh. Bangladesh Heart Journal 2021; 36(2): 164-168

Comparison of Angiographic Severity of Coronary Artery Disease between Premenopausal and Postmenopausal Women with Acute Coronary Syndrome

Background: The risk of coronary artery disease in women after menopause sharply rises in contrast to that of women before menopause because of hormonal protection against atherosclerosis. No research work has been done so far to see the angiographic pattern and severity of coronary artery disease in premenopausal women and their comparison with those of postmenopausal women. This study will help understand the pattern and severity of CAD both in premenopausal and postmenopausal women. Methods: This cross sectional analytical study was conducted over 100 ACS female patients who were purposively selected and agreed to do coronary angiogram during index hospital admission. Among them 50 patients were premenopausal status with CAD constituted study group I and another 50 postmenopausal women with CAD constituted study group II. The main objective of the study was to compare the angiographic severity of coronary artery disease between premenopausal and postmenopausal women with acute coronary syndrome. Angiographic severity of CAD was assessed by vessel score, Gensini score and Friesinger score. Results: LAD was the common artery involved (76% vs. 56%) followed by RCA (72% vs. 36%) and LCX (62% vs. 30%) in group-II compared to group-I and involvement of individual coronary artery was statistically significant (P values were 0.03, 0.003 and 0.001 respectively). Critical stenosis (70-99%) involving the all three major epicardial vessels (LAD, LCX and RCA) were found most frequently in group-II and the percentage of lesions were 56% vs. 30%; 56% vs. 22% and 54% vs. 22% respectively (p< 0.05). The vessel score of the study patients revealed that singe vessel involvement was significantly higher in group-I (52% vs. 24%) (p=0.003) and triple vessel involvement was found significantly higher in group-II (40% vs. 12%) (p=0.001). Severity assessment by Friesinger score showed normal (0) and low (1-4) Friesinger score significantly higher in group-I patients (P=0.04 and P=0.007 respectively) and high Friesinger score (11-15) was found significantly higher in patients in group II (p=0.001). Severity assessment by Gensini score of the study patients revealed significantly higher mild Gensini score in group-I patients (P=0.002) and severe Gensini score in group II patients (p=0.002). Conclusion: Coronary artery disease is one of the major important problems not only in postmenopausal women but in premenopausal women also. Postmenopausal women suffer from more triple vessels involvement, more diffuse and severe disease. This study results point out that premenopausal women suffer from less severe coronary artery disease and there is a trend to involve mid LAD more frequently in comparison to other two major coronary arteries and LM coronary artery in comparison to postmenopausal women. Bangladesh Heart Journal 2021; 36(2): 113-123

A Case Report on Spontaneous Coronary Artery Dissection Managed by Percutaeneous Coronary Intervention (PCI)

Background: Spontaneous coronary artery dissection (SCAD) is frequently underdiagnosed and often considered as a rare cause of acute coronary syndrome (ACS). Although it predominantly affects young women in the peripartum period, it can also occur in men. Most of the reported dissections have occurred in the left anterior descending coronary artery. The optimal treatment modalities are yet to be defined. Case Summary: A 50- year-old man who presented to us at National Institute of Cardio-Vascular Diseases (NICVD), Dhaka with an acute Non-ST-elevation myocardial infarction secondary to a spontaneous dissection of the Left anterior descending coronary artery. Due to ongoing chest pain, percutaneous coronary intervention (PCI) was done with drug eluting stent (DES) successfully, and the patient was discharged from the hospital on medical therapy. Conclusion: All clinicians should remain vigilant and aware of this condition, as patient outcomes and treatment guidelines differ substantially from conventional atherosclerotic ACS. Although initial conservative strategy is preferred strategy in SCAD management but timely intervention is warranted in selected cases. Bangladesh Heart Journal 2021; 36(2): 151-157

Coronavirus Disease 2019: One Year Experience at Tertiary Care Cardiac Hospital

Background: The Coronavirus Disease 2019 (COVID-19) pandemic is a significant challenge particularly for low and middle-income countries like Bangladesh. Interventions such as home isolation, frequent hand washing, wearing face mask, maintaining social distancing are difficult to implement in densely populated areas. The aim of the study was to delineate demographics, clinical manifestations, treatment modalities and outcomes of COVID-19 affected patients of our hospital. Methods: This prospective observational study was carried out at National Heart Foundation Hospital & Research Institute of Bangladesh between 08 March 2020 to 07 March 2021. During this period all admitted patients who subsequently were diagnosed as COVID positive and health care personnel of this hospital, who experienced fever or respiratory symptoms or came in close contact with COVID-19 patients at home or their workplace & become COVID positive were included. Results: During this one-year period a total of 769 COVID positive patients were detected in our hospital. Mean age of the patients was 48.16 ±15.63 years (range 1-92 years). Two third were male (64.9% vs 35.1%) and had multiple co-morbidities. One fifth of the patients were (19%) asymptomatic. The mean duration of onset of symptoms to test was 3.72±3.7 days. Most common symptoms were fever (65.3%), cough (37.1%), shortness of breath (33.6%) and fatigue (27.8%). Other symptoms were bodyache (18.6%), headache (16.6%), anosmia 16%), sore throat (12.1%), diarrhoea (6.8%), dizziness (5.3%), generalized itching (3.8%). Nearly two third of the COVID positive patients (63.2%) had a diagnosed cardiovascular disease at onset and remaining 36.8% patients presented with only COVID-19 disease. About 75% patients received ivermectin, 5.1% patients received favipiravir and 4.4% patients received remdesivir. Three fourth (74.38%) of patients were hospitalized and remaining one fourth (25.62%) patients were treated either in home isolation or in institutional isolation. Most of the patients recovered, with a case fatality rate of 3.5%. Diabetes, hypertension and age ≥50 years were the independent predictors of mortality. Conclusion: Although most of the patients had good outcome the study revealed 3.5% case fatality. Male with multiple co-morbidities were predominantly affected by COVID 19. Fever, cough, shortness of breath and fatigue were common presenting symptoms. Bangladesh Heart Journal 2021; 36(2): 89-97

Triglyceride to High Density Lipoprotein Cholesterol Ratio in Acute Myocardial Infarction And Its Relationship with Angiographic Severity

Background: In acute myocardial infarction (AMI) the extent of the coronary artery lesion is evaluated by coronary angiogram (CAG). Recent evidences suggest that, ratio of triglyceride and high-density lipoprotein cholesterol (TG/HDL-C) could be a non-invasive marker for the prediction of the extent of coronary artery lesion. The aim of this study was to evaluate the association between TG/HDL-C ratio and the extent of coronary artery lesion assessed by coronary CAG among AMI patients. Objective: The aim of this study was to assess relationship between TG to HDL-C ratio and extent of coronary artery lesion in AMI patients. Materials & Method: This cross-sectional study was carried out in the Department of Cardiology, Chittagong Medical College Hospital in 224 admitted AMI patients. Blood samples were taken within 24 hours of admission following AMI for fasting lipid profile assessment, (total cholesterol (TC), HDL-C, low-density lipoprotein cholesterol (LDL-C) and TG). Each patient was underwent CAG within 2 to 6 weeks of the events and angiographic findings were classified according to presence of significant stenosis, number of vessel involved and Gensini score. Results: The subjects consisted of 197 males and 27 females with a mean age of 51.24 (±11.22) years. Mean value of TC was 185.74 (±41.96) mg/ dL, TG was 222.17 (±99.05) mg/dL, HDL-C was 38.92 (±5.46) mg/dL, LDL-C was 127.99 (±36.94) mg/dL, TG/HDL-C was 5.91 (±2.99), median Gensini score was 28 (Range:1-146). Analysis of receiver operating characteristic curves showed that only TG/HDLC and TG were useful for detecting high Gensini score (score >42), with the former more area under the curve (AUC: 0.611; 95% CI: 0.531-0.691; p=0.008). The TG/HDL-C was an independent predictive factor (Odds ratio: 2.706; 95% CI: 1.397-5.242; p = 0.003) for the presence of significant coronary artery lesion on CAG. Linear regression analysis revealed that, age and TG/HDL-C ratio significantly predicted Gensini score. Conclusion: TG and HDL-C ratio was independently associated with extent of coronary artery lesion. Bangladesh Heart Journal 2021; 36(2): 82-88

High Bleeding Risk (HBR) patients Percutaneous Coronary Intervention-a Challenge to Deal with

Coronary artery disease (CAD) is one of the leading causes of death in our patient population. In the era of cardiovascular intervention, Percutaneous coronary intervention (PCI) is one of the most important modalities in treating these group of patients. Several CAD risks factors and co-morbid conditions are key responsible factor of procedural success. High bleeding risk (HBR) patients undergoing PCI is not an uncommon phenomenon. Incidences and prevalence of HBR patients with CAD and their management by PCI is not well addressed in our literature. PCI in HBR patients carries potential risk of intracranial hemorrhage (ICH) and lifethreatening bleeding. Therefore, careful pre-PCI assessment of possible risk or threats of post-PCI complications in patients with HBR are deem necessitate to understand. We recommend forming multicenter common consensus and to form a guideline in treating HBR patient by PCI. Thus, to reduce post procedural complication and subsequent improvement of mortality and morbidity in HBR patients undergoing PCI in both ST segment elevated myocardial infarction (STEMI) and as well as non-STEMI. Bangladesh Heart Journal 2021; 36(2): 133-138

A Case Report on Chronic Digoxin Toxicity

Digitalis glycosides are among the oldest drugs used in cardiology. Nowadays, due to the limited indications for their use (advanced heart failure, usually concomitant with atrial fibrillation), cases of toxicity induced by this class of drugs are rarely observed. Digoxin produces a positive inotropic and bathmotropic effect on the heart, but has a negative chronotropic and dromotropic effect. Cardiac glycosides have a narrow therapeutic window, so digitalis treatment can easily lead to symptoms of overdose. In patients taking digoxin, the drug therapeutic level should be maintained at 1-2 ng/ml; the toxic effects occur at concentrations > 2.8 ng/ml and are mainly related to disturbances of cardiac function and of the circulatory system, as well as gastrointestinal symptoms and CNS disturbances. Here, a 65-years-old patient who was hospitalized following chronic ingestion with acute renal impairment. In spite of rapidly applied gastric irrigation and administration of activated charcoal, the drug level in the patient’s blood was estimated at 8.5 ng/ml. During her stay on the ward, typical symptoms of severe toxicity were observed: from gastric symptoms (severe nausea, vomiting) to conduction disturbances. Type I, moitz type 1 and 2 AV blocks were detected, as well as some supraventricular extrasystoles. These conduction disorders required the use of temporary endocardial pacing. Due to the unavailability of specific antidotes (antidigitalis antibodies) and lack of efficient methods of extracorporeal elimination of the drug, symptomatic treatment comprising the correction of electrolyte disturbances and heart rate control remains the most effective. Bangladesh Heart Journal 2021; 36(2): 139-144

Radiofrequency Catheter Ablation for Supraventricular Tachycardias: A Six-Year Single Centre Experience at NICVD

Pharmacological therapy is mostly employed in the management of supraventricular tachyarrhythmias in different part of the world including Bangladesh. However, Radiofrequency catheter ablation has been found to be highly effective and safe in the treatment of such tachyarrhythmias. Objective: The current study is aimed at sharing our experiences of 842 patients who presented with Supraventricular tachycardias and were diagnosed by EPS and treated with Radiofrequency catheter ablation. Methods: This descriptive study has been carried out in the cardiac electro physiology Department of NICVD, Dhaka, Bangladesh from 2nd January 2015 to 31st December, 2020. Electrophysiology study(EPS) was carried out to identity and diagnose the mechanism of different SVTs in 842 consecutive patients. RF catheter ablation was used to interrupt the tachycardia circuit. Results: Out of a total 842 patients who underwent Electrophysiology study, 435 were found to have atrioventricular nodal re-entry tachycardia (AVNRT) as underlying mechanism and 391 were having accessory pathway responsible for the reentry mechanism; of these accessory mediated tachycardia, 250 patients were manifested accessory pathway (WPWS); 141 were concealed accessory pathway (out of them 365 were presented with orthodromic and 26 as antidromic reciprocating tachycardia); moreover among the accessory pathway 231 patients were found having left sided accessory pathway whereas 155 having right sided pathway; 12 patients were having focal atrial tachycardia and 4 were found atrial flutter as the underlying cause for SVT. Radiofrequency catheter ablation was used with an overall success rate of 95%, recurrence rate of 2% without any significant complication. Complication: One patient developed pulmonary thrombo-embolism, 6 patients developed DVT of right lower limb, 4 patients developed complete heart block. Conclusion: RF catheter ablation is safe and highly effective mode of treatment of different types of supraventricular tachyarrhythmias which is emerging and becoming popular in our country. Bangladesh Heart Journal 2021; 36(2): 68-73

Comparison of Risk Factors & Angiographic Profiles between Young Patients with ST Segment Elevation Myocardial Infarction and Non-ST Segment Elevation Myocardial Infarction

Background: Coronary artery disease is the leading cause of death in the world. Advancing age is a well-recognized risk factor for acute myocardial infarction (AMI). Myocardial infarction is less common in young adults. Prevalence of acute coronary syndrome in young individuals is increasing progressively. These patients have different risk profile, presentation and prognosis. Early recognition and risk factor modification in this population sub-set is of key importance. Objectives: The purpose of the present study was to determine the differences in risk factors and coronary angiographic profile of young patients with ST-segment elevated myocardial infarction (STEMI) vs. those with non-ST-segment elevated myocardial infarction (NSTEMI). Methods: In this cross sectional analytical study total 135 patients (70 STEMI and 65 NSTEMI) aged ≤45 years were enrolled to see the differences of risk factors and angiographic profile. Results: The mean age of the study population was 39.39±5.12 years and the study showed male predominance (90.40 % was male and 9.60 % was female). Smoking/tobacco consumption was significantly higher in STEMI patients, whereas diabetes mellitus and hypertension were more prevalent in NSTEMI patients. The frequency of single vessel disease and involvement of left anterior descending artery was significantly higher in young STEMI patients. In case of young NSTEMI patients frequency of triple vessel disease, noncritical coronary artery disease and involvement of left circumflex coronary was significantly higher. The frequency of double vessel disease and involvement of left main coronary artery was also nonsignificantly higher in young NSTEMI patients. There was no significant difference regarding involvement of right coronary artery. Conclusion: There are significant differences between young STEMI and young NSTEMI patients in respect to risk factors and angiographic profile. Key words: Young patient, STEMI, NSTEMI, Risk factors, Coronary angiographic profile. Bangladesh Heart Journal 2021; 36(2): 124-132

Redo MIDCAB in a Septuagenarian in our Setting, Fantasy or Fact? - A Case Report

Worldwide growth in elderly population has led to an upsurge in the number of septuagenarian (>70 years of age) patients requiring surgical treatment for coronary artery disease. Elective coronary artery bypass grafting (CABG) in the older patients are associated with acceptable risks of adverse events and should be undertaken for appropriate indications without unnecessary hesitation. Redo coronary surgeries carries one of the highest mortality rates amongst redo cardiac surgeries, both separately or in combination with other pathologies. As a result, minimally-invasive direct coronary artery bypass (MIDCAB), was preferred to avoid the complications of re-sternotomy. We hereby present a case report of a septuagenarian patient with post CABG (2014) unstable angina with old myocardial infarction (extensive anterior) who was treated successfully, by us and to our best knowledge in the published articles this is probably the first time, a re-do MIDCAB technique has been implemented in our country. Bangladesh Heart Journal 2021; 36(2): 145-150