Poor Trends in Glycemic, Weight and Blood Pressure Control during Screening in Population among Small town of Karachi.

Introduction: Diabetes is common cause of mortality in adults globally due to the increase in the risk of vascular complications. Pakistanis are an ethics group having an inherent predilection to develop diabetes. But this rise in incidence and prevalence is associated with demographics a social pattern, life style, unawareness due to low-literacy rate thus leading to obesity in the country. The high number of people in the pre-diabetic state or with undiagnosed diabetes represents large pool of individuals in rural areas than urban areas. Aims and Objective: Knowing the prevalence of these comorbidities like Diabetes, obesity and Hypertension contributing with each other is important for determining the size of the population that may benefit from strategies that reduce blood pressure and weight while controlling blood glucose. Prevention and control need to be structured at all levels of prevention and through the Promotion of early detection of diabetes through screening and diabetes education. Material and Methods: All persons aged 20-70 years attending the medical camps organized in small towns near to Karachi during (2017 June-2021 June) were tested for diabetes for free with help of Sindh Graduate Association and Go Red for Women Program Pakistan Cardiac Society. Data on their age, gender, height, weight, diabetes status and blood pressure were also taken. Basal mass Index was calculated and stratified as per WHO classifications. 2120 persons were screened but complete data for 1289 persons was available for analysis. Result: Out of 1289 screened people who attended the medical camps, 377 were known diabetics with mean age was 47.5 years with 66% being above 40. 60.2% had poor glycemic control using an optimum of <7.8 mmol/L, 54.59% had poor glycemic control with blood sugars exceeding 10 mmol/L. patients with HBA1c<7%, 50% being hypertensive in spite of the treatment. 62% of women were either overweight or obese then 33.3% in men. BMI above 30 kg/m2 as measure of obesity was found in 32%. in all those who were known diabetics. 12% (92) of those not known to have diabetes had either impaired glucose tolerance or were newly diagnosed diabetics. Conclusion: In our Study the Large proportion of diabetics were found with poor glycemic control. The majority of known diabetes patients were also at risk due to owning overweight, obesity and poorly controlled blood pressure, Emphasis should be on the promotion of early detection of diabetes through screening and diabetes education in under develop areas of Pakistan.

Percutaneous Coronary Interventions in Elderly Patients: Experience from a Tertiary Care Center from Developing Country

Objective of the study: To assess the outcome of Percutaneous coronary intervention in elderly in terms of success and complications. Methods: Retrospective data review of 887 consecutive cases of percutaneous interventions done at Karachi institute of heart diseases from 2015-2020. We divided the patients in three age groups younger (<65 years, n=592); older (65 to 75 years, n=201); and elderly (>=75 years, n=94). Immediate and six months outcomes of in hospital vascular complications, death, myocardial infarction, repeat target lesion revascularization and stroke were compared between these groups. Result: The vascular complications was in three groups (relative risk 3.2% vs 2.9% vs 4.3% with p=0.56) respectively. The relative risk of periprocedural Myocardial infarction in elderly/older patients was not higher than young patients with (OR of 0.6 with 95% CI 0.3 vs 1.4 with P=0.35), so was the need of repeat target revascularization with (OR of 0.3 95% CI 0.2 vs -1.6 with P=0.85), the risk of stroke following procedure was minimal (OR of 0.7 95% CI 0.4 vs 1.6 P=0.4). The in-hospital mortality was higher in elderly with (OR with 95% CI 1.0 vs 2.0 vs 3.4 P=0.03) in three groups. The six months outcomes of myocardial infarction in elderly were also not higher than younger pts (OR 0.7 vs 0.4 P=0.58). so was the need for repeat target revascularization (OR 0.5 vs 0.3 P=0.6). The six-month mortality in three groups was high in elderly (OR with 95% CI 1.5% vs 3.4% vs 4% with P value of 0.04). Conclusion: The procedure success in elderly patients was similar to younger patients, but in hospital and six months mortality was higher in elderlies.

Heart Disease in Women

All women face the threat of heart disease. Knowing the symptoms and risks unique to women, as well as eating a hearthealthy diet and exercising, can help protect you. Heart disease is often thought to be more of a problem for men. However, it’s the most common cause of death for both women and men in the United States. Because some heart disease symptoms in women can differ f Heart attack symptoms for women. The most common heart attack symptom in women is the same as in men some type of chest pain, pressure or discomfort that lasts more than a few minutes or comes and goes. But chest pain is not always severe or even the most noticeable symptom, particularly in women. Women often describe it as pressure or tightness. And, it’s possible to have a heart attack without chest pain. Women are more likely than men to have heart attack symptoms unrelated to chest pain, such as: Neck, jaw, shoulder, upper back or abdominal discomfort, Shortness of breath, Pain in one or both arms, Nausea or vomiting, Sweating, Lightheadedness or dizziness, unusual fatigue, Indigestion. These symptoms may be vague and not as noticeable as the crushing chest pain often associated with heart attacks. This might be because women tend to have blockages not only in their main arteries but also in the smaller ones that supply blood to the heart-a condition called small vessel heart disease or coronary microvascular disease. Women tend to have symptoms more often when resting, or even when asleep, than they do in men. Emotional stress can play a role in triggering heart attack symptoms in women. Because women don’t always recognize their symptoms as those of a heart attack, they tend to show up in emergency rooms after heart damage has occurred. Also, because their symptoms often differ from men’s, women might be diagnosed less often with heart disease than men are. If you have symptoms of a heart attack or think you’re having one, call for emergency medical help immediately. Don’t drive yourself to the emergency room unless you have no other options. Rom those in men, women often don’t know what to look for

Effects on Cerebral Oxygen Balance in Coronary Artery Bypass Grafting: A Comparison of Conventional and Minimal Extracorporeal Circulation

Objective: To investigate the cerebral oxygen balance difference between minimal extracorporeal circulation (MECC) and conventional extracorporeal circulation (CECC) during coronary artery bypass grafting. Methods: 20 patients undergoing coronary artery bypass grafting with cardiopulmonary bypass (CPB) were divided into two groups, the CECC group (n=10) and the MECC group (n=10). Blood withdrawn from radial artery and right jugular vein were analyzed at the following timepoints: during the anesthesia induction (T1), before CPB (T2), the initiation of CPB (T3), aorta crossclamped (T4), after temperature decreased (T5), during stable hypothermia (T6), initiation of rewarming (T7), aorta unclamped (T8), after weaning of CPB (T9), end of the operation (T10).The artery oxygen content (CaO2 ) and cerebral oxygen extraction ratio (OER) were calculated. The mean artery pressure (MAP), hemoglobin (Hb), nasopharyngeal temperature (NPT), and pump perfusion flow were recorded during the operation. Results: (1) MAP and Hb of MECC group were significantly higher than those in the CECC group from T3 to T10 (P<0.05); perfusion flow in MECC group during CPB was significantly lower than those in CECC group (P<0.05); NPT in MECC group was significantly higher than those in CECC group (P<0.05). (2) During T3-T4 and T8-T9, jugular venous oxygen saturation in CECC group was significantly lower than those in MECC (P<0.05); OER in CECC group was significantly higher than those in MECC group (P<0.05). (3) The arterial lactic acid and venous lactic acid in these two groups were decreased gradually from T3 to T10. Thearteriovenous difference in lactic acid in CECC group were higher than those in MECC group during T3-T4 and T8-T9 (P<0.05). Conclusion: Patients undergoing coronary artery bypass grafting with MECC enjoy more stable blood pressure, less intense hemodilution and lighter temperature disturbance than those with CECC, which indicating a better cerebral oxygen balance in CABG.

Treatment of Iatrogenic Coronary Artery Dissection in Resource Constraint in Cath-Lab, A Retrospective Study

Introduction: Coronary Artery Dissection is a well-known serious complication of invasive procedures (e.g. coronary angiography, balloon angioplasty and surgical cardioplegia) and is due to mechanical injury of the arterial wall by interventional devices used during procedures needing skilled operator to manage it timely. Objective: We wanted to look at these large tears that can dramatically affect blood flow and result in severe complications to understand where they happen most and how efficient are we at managing them for our patients in limited resources of the Cath-labs in developing countries. Methods: We reviewed the record of 28 (3.4%) cases of large dissection found in 806 patients who underwent coronary angioplasty in Cath lab of Cardiology Department of Dow University of Health Sciences Karachi. We analyzed as per American College of Cardiology/American Heart Association (ACC/AHA) criteria of the type of lesion, chronic total occlusion, calcification, intra-procedural dissection, and vessel site, related complications and management strategies. Results: Among the 806 patients that underwent per-cutaneous coronary intervention during 3 years (2014-2017) period at Cath-lab of Cardiology Department of Dow University of Health Sciences Karachi, 28 (3.4%) patients were found to have extensive dissection. Out of 10 patients who had immediate angioplasty and stenting for closure of dissection 8 patients were successfully treated and 2 (7.1) died during procedures. 8 (28.5%) needed immediate coronary artery bypass surgery. 10 (35.7%) out of the 28 (3.4%) patients were managed by further hospitalization with medical treatment out of them 3 patients needed angioplasty procedures. There were no late deaths. Conclusion: Coronary artery dissection remains a common occurrence during PCI since pre-stent procedures and clinical sequelae have been minimized by the routine use of coronary stents. Rapid recognition and attention to the angiographic appearance of the dissection is essential to the successful management of this complication. None the less, patients with extensive dissection who are free from the manifestation at the end of the procedure can be managed conservatively. Attempts should be made to stabilize extensive dissection during coronary angioplasty so that surgical intervention can be delayed or avoided altogether if possible.

Plasma Renin Activity after Diuretic Treatment in Patients with Stable Heart Failure: With Special Reference to its Association with Electrolyte Chloride

A recent study reported an intimate association between urinary chloride (Cl) and plasma renin activity (PRA) in acute heart failure (HF) status, reflecting normal functioning of the ‘tubulo-glomerular feedback’ mechanism. Whether the ‘tubuloglomerular feedback’ mechanism functions normally in stable HF status, however, is unclear. This study examined whether the ‘tubulo-glomerular feedback’ mechanism functions normally under resolution of worsening HF after decongestive therapy. Data from 26 patients with acute HF and its recovery after decongestive therapy were analyzed. Clinical tests included measurement of peripheral blood tests, serum and spot urinary electrolytes, plasma neurohormones, and fractional urinary excretions of electrolytes. In a total of 26 patients, PRA increased after acute HF treatment (from 1.64±2.0 to 5.48±6.1 ng/ mL/h, p=0.002). Changes in the serum logPRA and urinary Cl concentration from worsening to its recovery tended to be inversely correlated (R2 =0.12, p=0.085) and logPRA and the serum Cl concentration at recovery were inversely correlated (R2 =0.23, p=0.01). When divided into 2 groups (n=13 in each) according to the median PRA, the group with greater PRA changes showed a larger decrease in the urinary Cl concentration (from 110±44 to 72.8±38, p=0.03). The group with higher PRA at recovery showed a lower serum Cl concentration than the group with lower PRA at recovery (102±6.5 vs 107±4.2 mEq/L, p=0.04). In conclusion, the association between PRA and the serum/urinary Cl concentration is blunted in stable HF under-decongestive therapy, possibly due to the physiologic status under full cardiovascular medication compared with that in acute HF status.

Mental Stress and Multiple Risk Factors of Cardiovascular Diseases with Regional Variations in Women of Urban and Rural Areas of Sindh, Pakistan

Introduction: The high prevalence of risk factors in women in developing countries of South Asia appears to have been translated into early and severe CHD in contrast to their counterpart in the first world nations, which has been related to obesity and insulin resistance and genetically determined increased lipoprotein Lp(a) levels. Mental stress due to urbanization, sedentary life style and physical inactivity may be the most important factor initiating obesity and the clustering of all other risk factors hypertension, dyslipidaemia and (WHR). These risk factors vary in different regions of South Asia. Aims and Objectives: Our aim of the study was to describe and analyse differences between the frequency of risk factors such as psychological stress due to, socio-economical aspects, life style especially physical activity, and health behaviours which may contribute in the course of CAD in women of both rural and urban areas of Pakistan because no such significant data is available in women with CAD. Study Design: This descriptive cross-sectional comparative study was conducted in Cardiology Department of Dow University of Health and Sciences Karachi, Pakistan, from March 2014 to March 2016 by filling a questionnaire and laboratory data. The study group comprised female subjects around 577 (Urban 347 {60.1%} and Rural 230 {39.9%}) women ranged from 25-65 years of age who underwent coronary angiography and had definite coronary atherosclerotic diseases. Our study was conducted by examining the psychological stress in women of both areas and its strength of association with frequency of other risk factors in female patients of urban and rural areas with definite CHD taking account the difference in age and education level into account. Result: Analysis of this study conducted at department of Cardiology in Dow University Karachi from March 2014 to March 2017 revealed that the women of rural area were comparatively more physically active then women of urban area. Prevalence of mental stress, hypertension, diabetes, obesity, higher BMI, hyperlipidaemia (especially TC) waist and hip circumference of both areas were found to be different after adjustment made for age. A considerable association was found between psychological stress and other factors in ischemic heart disease patients showing the p-value (p=0.043). Psychological stress was found 82% in both groups and (13%) women had no stress rated as normal more in rural (26%) vs (04%) in urban population. Physical inactivity in women with CHD was found in 92% urban in contrast to 45% in rural population, (p=0.009). Hypertension prevalence was more in urban 253 in comparison to 151 women in rural area. Diabetes Mellitus was also found more in urban than rural population, especially in age below 50, 79 (23%) urban vs 60 (26%) in rural population. Women beyond 50 years of age, 85 (24%) urban vs 64 (27%) rural area had prevalence of obesity comparatively higher in urban residents 71 (20%) than 44(%) in rural dwellers and 32 (9%) urban vs 16 (7%) in rural women in age range below 50 years. Higher waist circumstance was observed more in urban residents (4.8 cm) whereas BMI was more (1.8 unit) in women of rural area than urban women. Prevalence of smoking and nicotine chewing was relatively higher in urban population in below 50 years of age with 30 (09%) urban vs 13 (05%) in rural women and in age beyond 50, 11 (03%) urban vs 10 (04%) in rural women was witnessed. Average total cholesterol, serum triglycerides and LDL were found to be higher in urban compared to rural area residents and HDL was comparatively lower in urban area group. Mean cholesterol level was seen at average of 353 mg% in urban vs 223 mg% in rural population. Serum cortisol level showed significant variation in urban group 19.1 vs 14.2 in rural group (sample, as well as serum fibrinogen was raised more raised in urban population). Conclusion: Our study shows increased prevalence of mental stress and physical inactivity in female residents of urban area leading to Higher blood pressure, DM, dyslipidaemia and central obesity specially in Waist circumference than rural area. The mental stress induced by excessive demands of work at home and at working place with too little control is not unique to women of urban areas.

Clinical Significance of Spot Urinary Chloride Concentration Measurements in Patients with Acute Heart Failure: Investigation on the Basis of the ‘TubuloGlomerular Feedback’ Mechanism

Urinary chloride (Cl) is the key electrolyte for regulating renin secretion at the macula densa under the ‘tubulo-glomerular feedback’. Whether or not Cl filtrated into the urinary tubules actually associates with plasma renin activity (PRA) in clinical heart failure (HF) remains unclear. Data from 29 patients with acute worsening HF (48% men; 80.3±12 years) were analyzed. Blood and urine samples were immediately obtained before decongestive therapy after the patients rested in a supine position for 20-min. Clinical tests included peripheral blood tests, serum and spot urinary electrolytes, b-type natriuretic peptide (BNP), plasma neurohormones, and fractional urinary electrolyte excretion. In the 29 patients, urinary Cl concentrations inversely correlated with logarithmically transformed PRA (R2 =0.41, p=0.0002). The correlation was weaker in worsening chronic HF patients (R2 =0.32, p=0.01) compared with de novo HF patients (R2 =0.70, p=0.0026). Patients were divided into 2 groups according to the median urinary Cl concentration, a low group and a high group. Compared with the high group (100~184 mEq/L; n=14), the low group (4~95 mEq/L; n=15) exhibited more renal (serum creatinine; 1.45±0.63 vs 1.00±0.38 mg/d, p=0.029) and cardiac (log BNP; 2.99±0.3 vs 2.66±0.32 pg/mL, p=0.008 p=0.008) impairment, and higher PRA (3.42±4.7 vs 0.73±0.46 ng/mL/h, p=0.049), and lower fractional excretion of urinary Cl (1.34±1.3 vs 5.33±4.1%, p<0.0001). The present study provides clinical data on the possible functioning of urinary Cl involved in the mechanism of ‘tubulo-glomerular feedback’, and thus advances our understanding of the clinical meanings of the significance of urinary Cl concentration measurement.

Research Progress on the Relationship between Lipoprotein Associated Phospholipase A2 and Coronary Atherosclerotic Heart Disease

Coronary atherosclerotic heart disease is a common disease which seriously endangers human health. The incidence rate is increasing year by year and the age of onset is becoming younger. As a kind of Inflammatory factors of vascular, Lipoprotein associated Phospholipase A2 (Lp-PLA2) can promote the progress of inflammation and coronary atherosclerosis, and its serum level can reflect the stability of atherosclerotic plaque. Among the risk factors of coronary heart disease, Lp-PLA2, as a supplement to the traditional risk factors, has a significant reference value for the prediction of coronary heart disease. More and more studies have found that Lp-PLA2 has a significant potential value in evaluating the prognosis of coronary heart disease, especially in acute coronary syndrome patients. This review summarizes the research progress of Lp-PLA2 on the pathogenesis, detection methods, independent risk factors of predicting coronary heart disease and the treatment and prognosis evaluation of coronary heart disease.

Improved Patient Outcomes by Normalizing Sympathovagal Balance: Midodrine and Parasympathetic and Sympathetic Monitoring

A function of the Parasympathetic and Sympathetic (P&S) nervous systems is to maintain proper tissue perfusion, including of the heart and brain upon head-up postural change standing. Orthostatic dysfunction (OD) is associated with pooling of blood in the lower extremities, insufficient vascular support of the heart, and poor brain perfusion. Abnormal P&S responses to standing help to guide therapy for the individual patient. Midodrine is often the primary recommendation to correct P&S dysfunction upon standing. P&S Monitoring (Physio PS, Inc, Atlanta, GA) differentiates OD-subtypes in 2727 cardiology patients, serially tested. P&S Monitoring non-invasively, independently, and simultaneously measures P&S activity, including the normal P-decrease followed by an S-increase with head-up postural change (standing). S-Withdrawal (SW) and P-Excess (PE) are two types of autonomic dysfunction that are associated with OD. SW differentiates OD from Syncope (an S- excess with stand, e.g. Vasovagal Syncope). PE often masks SW by inflating the S-response to stand. OD based solely on BP and HR responses to provocation remains difficult to differentiate, especially early in its development and difficult to track upon follow-up. The latter is important to ensure relief of not only the abnormal BP response to stand (e.g. Orthostatic Hypotension) or HR (e.g. Postural Orthostatic Tachycardia Syndrome) but the SW or PE as well. SW underlies the majority of Dysautonomia patients with lightheadedness (whether masked or not, 82.0%, p=0.0061). Midodrine relieves SW and ultimately Lightheadedness and associated symptoms within 9 months (75.4%, p=0.0323). P&S Monitoring provides more information, enabling earlier and more specific diagnosis and therapy for improved patient outcomes. P&S dysfunction upon standing may be most well relieved by very low doses of oral vasoactive medications such as Midodrine (Proamatine), Mestinon (Pyridostigmine), or Northera (Droxidopa). In this study we focus on Midodrine.