Triple Vessel Disease Research Articles

Platelet Parameters May be Predictors of Coronary Artery Disease in Prediabetes: Rural Hospital-based Cross-sectional Study

Introduction: Prediabetes is a state of impaired glucose tolerance that often precedes overt diabetes mellitus and is frequently underdiagnosed. Glycation of platelet proteins leads to increased platelet reactivity which can be an essential predisposing event in the pathogenesis of coronary artery disease (CAD). Although research has been conducted to diagnose CAD in prediabetes and to assess platelet indices in prediabetes, there has been no attempt to assess platelet indices in prediabetic patients who have CAD. Methods: This cross-sectional study was carried out in a rural tertiary care center in Central India from September 2019 to August 2021. A total of 180 patients were enrolled in this study, having documented CAD in coronary angiography (CAG) and blood glucose levels in the diagnostic range of prediabetes by the criteria set by the World Health Organization. Platelet indices, glycosylated hemoglobin, blood sugar levels, and CAG findings were documented for all participants. Results: The mean platelet volume (MPV) in our study population was 9.58 ± 1.14 fL, platelet distribution width (PDW) was 15.69% ± 1.36%, plateletcrit was 0.3% ± 0.07%, and platelet count was 319 ± 44 × 103 cells/mm3. PDW was the best tool to predict double-vessel disease (P < 0.0001), while MPV (P = 0.6146) and PDW (P = 0.0266) were best predictors of triple-vessel disease. Conclusion: Platelet indices that are readily available investigations prescribed by clinicians routinely are significantly associated with blood sugar levels and can predict the severity of CAD in prediabetics in terms of the number of vessels involved. Early assessment of platelet indices in prediabetics can aid in the diagnosis and prognosis of CAD, thereby helping in planning early intervention.

Effects of monitoring exercise rehabilitation with target intensity on the patient with twice PCI: A case report.

As the core of cardiac rehabilitation (CR), early exercise rehabilitation is beneficial for patients with coronary heart disease (CHD), and center-based CR with target intensity is superior to home-based CR. However, there was no research to observe the effects of exercise rehabilitation on cardiopulmonary exercise capacity, oxygen uptake efficiency slope, endothelial function evaluated as flow-mediated vasodilation (FMD), and blood plasma lipoprotein-associated phospholipase A2 (Lp-PLA2) in CHD patients undergone percutaneous coronary intervention (PCI) for 3 months. A 57-year-old woman had been identified with triple vessel disease and undergone twice PCI for complete revascularization, however, there was no improvement in Lp-PLA2, FMD, and related indicators of cardiopulmonary exercise testing. Coronary angiography showed an 85% stenosis in the middle left anterior descending artery, an 85% stenosis in the proximity of a thick first-diagonal branch, a long 75 to 85% stenosis in the middle left circumflex artery, and a 90 to 95% stenosis in the proximal. The case was diagnosed as CHD. The patient obtained optimal medical therapy comprising therapeutic lifestyle changes, and began monitoring exercise rehabilitation with target intensity 3 months after the second PCI in the CR center. There were changes in cardiopulmonary exercise capacity, oxygen uptake efficiency slope, FMD, and Lp-PLA2 in the patient with 3 apparent stenotic coronary arteries who was done PCI twice, without or with postoperative exercise rehabilitation, respectively. We proved that monitoring exercise rehabilitation training with target intensity could improve the prognosis of chronic coronary syndrome patients, and it was never too late to do regular exercise rehabilitation.

Early and mid-term outcomes of off-pump versus on-pump coronary artery bypass surgery in patients with triple-vessel coronary artery disease: a randomized controlled trial

Background and aim of the studySeveral studies have compared early and late outcomes of on-pump coronary artery bypass grafting (CABG) and off-pump CABG. However, there is still an ongoing debate on this matter, especially in patients with triple-vessel coronary artery disease (3VD).MethodsWe randomly assigned 274 consecutive patients with 3VD to two equal groups to undergo on-pump CABG or off-pump CABG. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), including all-cause mortality, acute coronary syndrome, stroke or transient ischemic attack, and the need for repeat revascularization. The secondary outcomes were postoperative infection, ventilation time, ICU admission duration, hospital stay length, and renal failure after surgery.ResultsThe median follow-up duration was 31.2 months (range 24.6–35.2 months). The mean age of patients was 61.4 ± 9.3 years (range: 38–86), and 207 (78.7%) were men. There were 15 (11.2%) and 9 (7.0%) MACCE occurrences in on-pump and off-pump groups, respectively (P value = 0.23). MACCE components including all-cause death, non-fatal MI, CVA, and revascularization did not significantly differ between on-pump and off-pump groups. We observed no difference in the occurrence of MACCE between off-pump and on-pump groups in multivariable regression analysis (HR = 0.57; 95% CI 0.24–1.32; P value = 0.192). There were no statistical differences in postoperative outcomes between the off-pump and on-pump CABG groups.ConclusionsOff-pump CABG is an equal option to on-pump CABG for 3VD patients with similar rates of MACCE and postoperative complications incidence when surgery is performed in the same setting by an expert surgeon in both methods. (IRCT20190120042428N1).

Immediate results of percutaneous transluminal angioplasty in patients above 70 years

Background: Even in older patients, percutaneous transluminal coronary angioplasty (PTCA) is becoming a more widely acknowledged technique for revascularization. Because to its less intrusive nature, PTCA is a desirable option to coronary bypass surgery in this age category due to the increased frequency of postoperative mortality and treatment problems in older patients. Objective: Analyze the immediate and ongoing therapeutic efficacy of PTCA in individuals above 70 years. Methods: In the Hayatabad Medical Complex hospital in Peshawar, 6830 patients had PCI between April 2021 and August 2022. Throughout the trial period, interventions were performed on 102 male patients who were above 70 years. Results: Among the 102 patients, Thirty-two patients (31.37% of the total) had left ventricular ejection fraction (LVEF) lower than 40%. One hundred percent of patients with single vessel disease (SVD), 94 % and 72 % of participants with double vessel disease and triple vessel disease (TVD), respectively had successful procedures. The rate of major adverse cardiac event (MACE) in hospitals was 9/102 (8.82%). The 1-month MACE incidence was 10.78% (n=11) while the one-year MACE incidence was 17.64% (n=18), correspondingly.

Assessment of the Severity of CAD Regarding Number of Vessels Involved

Background: Coronary artery disease (CAD) is characterized by atherosclerotic plaque accumulation in the epicardial arteries. The dynamic nature of the CAD process results in various clinical presentations. Red blood cell distribution width (RDW) is a practical, widely available marker for assessing the severity of coronary artery disease and helps in the risk stratification of patients with CAD. This study aimed to analyze the severity of CAD regarding the number of vessels involved. Material Methods: This descriptive cross-sectional study included 124 purposively selected patients who underwent elective CAG in the Department of Cardiology, Chittagong Medical College Hospital, Chattogram, from January 2020 to June 2021. SPSS 23.0 software was used for processing and analysis at the end of the data collection period. Results: The age of the patients ranged from 32-75 years with a mean (±SD) age of 53.4 (±9.9) years. The majority of the patients (83.1%) were male with a male-to-female ratio of 4.9:1. On coronary angiography, the majority of the patients (51/124, 41.1%) had triple vessel disease, followed by double vessel disease in 23 (28.5%) patients, single-vessel disease in 31 (25.0%). In 19 (15.4%) patients no significant lesion was observed in any of the vessels. Gensini score ranged between 1 and 176 in the study with a median score of 56.77. The majority of the patients (69.4%) in the present study had a Gensini score ≥30 indicating severe stenosis. A positive correlation between RDW and coronary artery disease severity in terms of Gensini score (r=0.393). With the increase of RDW, the Gensini score increases. It was found statistically significant (p=<0.001) by Pearson’s correlation test. There was a positive correlation between RDW and CAD severity regarding the number of vessels involved (rho =0.5). With the increase of RDW, the number of involved vessels increases. It was found statistically significant (p=<0.001) by Spearman’s correlation test. The Median (IQR) value of RDW was 13.5 (13.0-14.0) in patients with mild stenosis compared to 14.5 (13.9-15.0) in patients with severe stenosis. This difference was statistically significant (p<0.001). The median (IQR) value of RDW was the lowest in patients without any significant stenosis in any of the coronary arteries [13.1% (12.7%-13.5%)] and was the highest in patients with triple vessel diseases [14.5% (14.1%-15.0%)]. Conclusion: This study demonstrated that RDW level was an independent predictor for CAD and the severity of coronary stenosis. So, it can be concluded that RDW is an inexpensive routine laboratory test that might help identify high-risk patients before planning for a more invasive treatment strategy.

Wellens’ syndrome following severe COVID-19 infection, an innocent coincidence or a deadly association: two case reports

BackgroundCoronavirus disease 2019 (COVID-19) has been associated with late-onset cardiovascular complications primarily due to a hypercoagulable state. Its association with Wellens’ syndrome, which reflects a stenosis in the proximal left anterior descending coronary artery, is not well established. We present two cases diagnosed with this syndrome following their COVID-19 acute phase despite taking adequate anticoagulation.Case presentationWe present two patients with incidental electrocardiography (ECG) showing the typical Wellens’-related changes, with an underlying severe triple-vessel coronary artery disease a few weeks following a severe COVID-19 infection associated with high inflammatory markers. The stenotic lesions were diagnosed by cardiac catheterization, and both patients underwent Coronary Artery Bypass Grafting successfully. Notably, patients’ baseline ECGs were normal, and they were maintained on Rivaroxaban 10 mg following their viral illness.ConclusionDespite advances in the preventive measures for COVID-19 complications, its pathophysiologic impact on vasculature and atherosclerosis is still incompletely understood. Further clinical trials must be conducted to study this association between Wellens’ syndrome and this virus to prevent life-threatening complications.

Association of Hs-CRP Levels in Patients with Acute Coronary Syndromes and it’s Correlation with Angiographic Severity of Coronary Artery Stenosis

Objectives: Significant advances have been made toward the development of biomarkers for prognostication of patients with atherosclerotic cardiovascular disease. One such marker is high-sensitivity C-reactive protein (hsCRP). It is a marker of inflammation mainly used to predict the risk of adverse cardiovascular (CV) events. Recent research also supports its role in atherogenesis. It is involved throughout the process of atheromatous plaque development. However, limited information is available about the relationship between levels of hs-CRP levels in patients presenting with acute coronary syndromes (ACS) and its association with outcomes. We conducted this study to assess the correlation between the levels of hs-CRP and the coronary angiographic findings in patients presenting with ACS and its correlation with outcomes. Materials and Methods: we carried an observational prospective study in patients presenting with ACS admitted to cardiology intensive coronary care unit in a tertiary care hospital. Patients underwent invasive coronary angiogram and serum Hs-CRP levels testing apart from other routine investigations. Correlation between severity of coronary stenosis, Hs-CRP levels and left ventricular ejection fraction (LVEF) at discharge was then assessed using statistical analysis. Results: Positive correlation was found between Hs-CRP levels and severity of coronary stenosis. Negative correlation was found between Hs-CRP levels and LVEF at discharge. Conclusion: We found that hs-CRP levels correlate well with angiographic severity. It was also observed that higher the hs-CRP levels more the number of vessels involved with patients with the left main + triple vessel disease (TVD) and TVD having maximum scores.

The Prevalence of Frank’s Sign and the Diagnostic Accuracy in Coronary Artery Disease Among Chest Pain Patients at Lampang Hospital, Thailand

Background: One of the leading cause of death in Thailand is coronary artery disease (CAD). There are several studies that demonstrated a significant correlation between diagonal earlobe creases (DELC) or Frank’s sign and CAD, but data in Thai populations still remains unclear. Because of Frank’s sign is easily to observe by health-care professional including medical students, so it was very interesting to use to identify risk of atherosclerosis of the patients in hospital which has limitation of resources. The purpose of the study was to assess the prevalence of Frank’s sign and evaluate the diagnostic accuracy in CAD among the angina chest pain patients at Lampang Hospital. Methods: This study was a cross-sectional, observational, study. Three hundred and nine patients with angina chest pain who underwent coronary angiography (CAG) and followed up at the coronary clinic at Lampang Hospital were enrolled in the study. Both ears of the patients were inspected for Frank’s sign. The accuracy of Frank’s sign was confirmed by three cardiologists and clinical data was collected in medical record form. We excluded the patients whose earlobe could not be clearly observed, including those with keloid/ulcer on the earlobe or those with no earlobe. The correlation of Frank’s sign and CAD were analyzed by using logistic regression and receiving operative curve (ROC) curve. Results: 64.4% of the angina chest pain patients (N=199) have demonstrated for Frank’s sign, unilateral Frank’s sign in 12.3% (N=38) and bilateral Frank’s sign in 52.1% (N=161). Twenty-one patients (6.8%) were normal CAG and 288 patients (93.2%) were significant CAD, single vessel disease CAD (N=86), double vessel disease CAD (N=83) and triple vessel disease CAD (N=119). The diagnostic accuracy of the Frank’s sign revealed that 64.6% for the sensitivity and 38.1% for the specificity. Besides, the positive predictive value (PPV) was 0.935 and for negative predictive value (NPV) showed 0.073. Nevertheless, the positive likelihood ratio (LR+) was 1.032 and 0.947 for the negative likelihood ratio (LR-). Moreover, the area under the curve (AuROC) of Frank’s sign with respect to detection of CAD was 0.513 (95% Confidence Interval was 0.385-0.642, P= 0.838). Conclusion: Frank’s sign was observed in two-third of angina chest pain patients at Lampang Hospital and mostly of the patients with Frank’s sign were significant CAD. The results of this study showed that Frank’s sign was a simple, non-expensive and non-invasive method for medical student and health-care professional to identify risk of CAD.

Clinical outcomes in end stage renal disease on dialysis and severe coronary artery disease: A real-world study

BackgroundThe optimal management of patients with end-stage renal disease (ESRD) on dialysis with severe coronary artery disease (CAD) has not been determined. MethodsBetween 2013 and 2017, all patients with ESRD on dialysis who had left main (LM) disease, triple vessel disease (TVD) and/or severe CAD for consideration of coronary artery bypass graft (CABG) were included. Patients were divided into 3 groups based on final treatment modality: CABG, percutaneous coronary intervention (PCI), optimal medical therapy (OMT). Outcome measures include in-hospital, 180-day, 1-year and overall mortality and major adverse cardiac events (MACE). ResultsIn total, 418 patients were included (CABG 11.0%, PCI 65.6%, OMT 23.4%). Overall, 1-year mortality and MACE rates were 27.5% and 55.0% respectively. Patients who underwent CABG were significantly younger, more likely to have LM disease and have no prior heart failure. In this non-randomized setting, treatment modality did not impact on 1-year mortality, although the CABG group had significantly lower 1-year MACE rates (CABG 32.6%, PCI 57.3%, OMT 59.2%; CABG vs. OMT p < 0.01, CABG vs. PCI p < 0.001). Independent predictors of overall mortality include STEMI presentation (HR 2.31, 95% CI 1.38–3.86), prior heart failure (HR 1.84, 95% CI 1.22–2.75), LM disease (HR 1.71, 95% CI 1.26–2.31), NSTE-ACS presentation (HR 1.40, 95% CI 1.03–1.91) and increased age (HR 1.02, 95% CI 1.01–1.04). ConclusionTreatment decisions for patients with severe CAD with ESRD on dialysis are complex. Understanding independent predictors of mortality and MACE in specific treatment subgroups may provide valuable insights into the selection of optimal treatment options.

Relation between thyroid hormonal status, neutrophillymphocyte ratio and left ventricular systolic function in patients with acute coronary syndrome.

Aim To examine a relation of thyroid function, neutrophil-lymphocyte ratio (NLR) with left ventricular function measured through the left ventricular ejection fraction (LVEF) in patients with acute myocardial infarction treated with percutaneous coronary intervention (PCI). Methods This prospective research involved 160 consecutive patients with acute myocardial infarction. Patients were divided into those with normal thyroid hormone status (n=80) and those with hypothyroidism (newly diagnosed) (n=80). Inflammatory parameters and parameters of hormonal status were taken for analysis: thyroid-stimulating hormone (TSH), thyroxine (T4), triiodothyronine (T3), free thyroxine (FT4), and free triiodothyronine (FT3). All patients underwent transthoracic echocardiographic examination (TTE) five days upon admission, and left ventricular ejection fraction (LVEF) was analysed. Results Significant difference between the two groups was verified in values of T3, T4, erythrocytes, haemoglobin, haematocrit, neutrophil, lymphocytes, NLR, C-reactive protein (CRP) and sedimentation rate. Patients with euthyroidism had a higher frequency of coronary single-vessel disease (p=0.035) and a significantly lower frequency of triple vessel disease (p=0.046), as well as a higher median value of LVEF (p=0.003). There was a significant correlation between LVEF with haemoglobin values (p=0.002), NLR (p=0.001), and CRP (p=001). Conclusion The altered status of the thyroid gland in acute myocardial infarction is associated with the severity of the coronary blood vessel lesion, LVEF and correlates with inflammatory response.

Association of type 2 diabetes with coronary risk factors, clinical presentation, angiography, coronary interventions and follow-up outcomes: A single centre prospective registry

Background & aimsTo determine variations in coronary artery disease (CAD) clinical presentation, interventions, and outcomes in patients with diabetes vs without, a prospective study was performed. MethodsSuccessive patients with predominantly acute coronary syndromes who underwent percutaneous coronary intervention (PCI) were enrolled from January 2018 to March 2021. Patients with diabetes were compared to those without diabetes to determine differences in clinical and angiographic features and outcomes. In-person and telephonic follow-up were performed. Primary outcome was cardiovascular death and co-primary were major adverse cardiovascular events (cardiovascular death, myocardial infarction, revascularization, stroke). Cox-proportional hazard ratios (HR) and 95% confidence intervals (CI) were calculated. Results5181 patients (men 4139,women 1042) were enrolled. Acute coronary syndrome(ACS) was in 4917 (94.9%) and diabetes in 1987 (38.4%). Patients with diabetes were older (61.1 ± 9.6 vs 59.7 ± 11.5years), with more hypertension (71.1 vs 45.5%), chronic kidney disease (3.0 vs 1.7%), previous PCI (13.5 vs 11.0%), past coronary artery bypass graft surgery (4.9 vs 2.4%), non ST-elevation myocardial infarction (59.6 vs 51.6%) and triple vessel disease (20.3 vs 17.2%) (p < 0.01). Duration of hospitalization was more in diabetes (4.2 ± 2.6 vs 4.0 ± 2.1 days, p = 0.023) with no difference in in-hospital deaths (1.4 vs 1.0%, p = 0.197). Follow up was performed in 1202 patients (diabetes 499,41.5%) enrolled from April 2020 to March 2021 (median 16.4 months). In diabetes there were more cardiovascular deaths (multivariate adjusted HR 2.38, CI 1.13–5.02) and all-cause deaths (HR 1.85, CI 1.06–3.22). ConclusionsCAD patients with diabetes undergoing PCI have more hypertension, chronic kidney disease, non ST-elevation myocardial infarction and triple vessel disease. At medium-term follow-up the incidence of cardiovascular and all-cause deaths is significantly more in these patients.

Cardiac Surgery in Birgunj: Early Experience

Introduction: Cardio-vascular diseases are growing up in developing countries and they are the leading cause of deaths in the world, especially in low- and middle-income population. Various procedure were included such as open thoracotomy, CABG, Mitral valve repair aortic valve repair, however we aimed to study difficulties in performing cardiac surgery and complication related to cardiac surgery.&#x0D; Material &amp; Methods: This retrospective study was carried out in Department of Surgery of National Medical College and Teaching Hospital, Birgunj, Parsa, Nepal. A total of 18 patients were included over period of 2019 to 2022 in this study. History and detailed clinical examination was performed as per the working proforma. Data analysis was done using SPSS (Statistical Package for social sciences), version 25.&#x0D; Result: Most of Coronary heart disease was seen in 40-59 years of age group with mean age of 48.2 years. A total of 83% patients were male. Triple vessel disease was the most common diagnosis (38.3% patients). Coronary artery bypass surgery (CABG) was most common surgery performed. 44.4% of patient develops complication out of which mortality occured in 11.11% of patient.&#x0D; Conclusion: To conclude, elective cardiac surgery is challenge in center like ours. Coronary heart disease (Triple vessels disease) was the most common indication of surgery.

Three years performance of Biodegradable Polymer Sirolimus Eluting Stent in all comer patients undergoing Percutaneous Coronary Intervention.

Introduction: Contemporary evidence suggest the comparable performance of biodegradable polymer sirolimus eluting stents (BPSES) with that of second generation durable polymer drug eluting stents. This study was done to evaluate the performance of BPSES in all comer patients undergoing percutaneous intervention (PCI) in real world setting over a period of three years. Materials &amp; Methods: This was a prospective observational study, wherein all comer consecutive patients undergoing PCI with BPSES (Yukon Choice Elite stent by Translumina Therapeutics, India) were enrolled and followed up for 3 years. The study's primary endpoint was the Device Oriented Composite Endpoint (DOCE), which included cardiac death, target vessel myocardial infarction (MI), and clinically driven target lesion revascularization (TLR); the co-primary endpoint was the Patient-Oriented Composite Endpoint (POCE), which included all-cause mortality, any MI , and any repeat revascularization and the secondary endpoint was definite or probable stent thrombosis (DST &amp; PST). Results: 301 patients with 502 lesions were treated with 485 BP-SES. Mean age of the study cohort was 61.6± 9.3 yrs and males were 79.1%. 18.6% patients were diabetic, 29.6% had ejection fraction less than 40% and 73.1% patients presented with acute coronary syndrome (ACS). Majority of the patient had triple vessel disease (TVD) (51.8%), multivessel PCI was done in 15.6% and complex PCI in 26.2% patients. A mean of 1.6 ±0.8 stents per patient with mean diameter 3.0 ± 0.3 mm and mean length of 27.2 ± 0.8 mm were placed. DOCE &amp; POCE occurred in 7.9% (cardiac death-4.8%, TLR-2.6% &amp; target vessel MI-0.4%) and 12.8% (All deaths-9.7%, any MI- 0.4% and any revascularisation-2.6%) patients respectively at three years follow-up. DST &amp; PST rate was 0.9% and 0.4% respectively in the study cohort. All the cases of stent thrombosis occurred within 30 days. Kaplan Meier analysis revealed that diabetes mellitus, low ejection fraction (EF), acute coronary syndrome (ACS), long stents and complex intervention had no impact on occurrence of DOCE &amp; POCE while using BP-SES in all-comer patient population. Conclusion: Present study showed favourable long term safety and efficacy profile of BP-SES for all-comer patients undergoing PCI.

A Case of Orthotopic Renal Transplant in a Patient with Diffuse Atherosclerosis

A 60-year-old male with long-standing diabetes, hypertension, and smoking developed an end-stage renal disease that necessitated hemodialysis. His drive-by angiograms revealed significant carotid and iliac calcifications and a triple-vessel disease on cardiac assessment. The abdominal aorta, common iliac, and the vascular tree below were all heavily calcified, according to a computed tomography angiography. Concerned about the location of the donor renal artery anastomosis, the decision was taken to do a left native kidney nephrectomy and orthotopic renal transplant. End-to-end anastomoses were made between the donor renal artery and splenic artery and between the donor renal vein and the recipient native kidney renal vein. The patient is doing well after the transplant, and the graft is functioning excellently with a creatinine of 0.9 mg/dl.

Smoking after a heart attack - a case report

A Middle aged man suffered acute myocardial infarction while at work and angiography confirmed triple vessel disease requiring stenting followed by lifelong medication. Important to note that upon follow up his lifestyle had not significantly changed, and he continued to smoke cigarettes. Soon after he developed severe low back pain which made him bed bound for a few weeks and further medications were added however all this could not deter him from smoking. This paper aims to discuss why some patients continue to smoke after such major life events. Keywords: smoking, heart attack

Massive Left Ventricular Thrombus in the Setting of COVID-19–Induced Systemic Thrombi

A 58-year-old White man with no known medical history initially presented to the emergency department for fatigue and was ultimately diagnosed with COVID-19. He was in stable condition and discharged to quarantine at home. He returned to the emergency department 2 weeks later with a chief report of progressive pain and swelling of his legs. Initial vitals were remarkable for a heart rate of 115/minute. Physical examination revealed edematous and erythematous lower extremities with weeping wounds. Laboratory workup was remarkable for a white blood cell count of 12.7 × 1,000/μL, platelet count of 81 × 1,000/μL, troponin I level of 0.678 ng/mL, brain natriuretic peptide level of 4,000 pg/mL, C-reactive protein level of 121 mg/L, lactate level of 3.7 mmol/L, and international normalized ratio of 1.5.Chest computed tomographic angiography revealed acute emboli of subsegmental pulmonary arteries of the left upper, middle, and lower lobes (Fig. 1). Echocardiogram revealed a severely dilated left ventricle with apical akinesis and an ejection fraction of 10% to 15%. Large, layered thrombi were seen in the apex of the left and right ventricles (Fig. 2). Duplexes of the lower extremities showed acute occlusive calf vein thrombi in the right posterior tibial and bilateral peroneal veins. Arteries were patent in both lower extremities. Venous duplex of the right upper extremity revealed acute superficial venous thrombi in the right basilic and cephalic veins. Cardiac magnetic resonance imaging was performed to assess viability, which revealed significant transmural scarring and a large thrombus (8 × 6 × 5 cm) occupying the mid- and complete apical left ventricle cavity (Fig. 3). Multiple small thrombi in the right ventricle apex were seen.Given the thrombocytopenia on presentation, there was concern for disseminated intravascular coagulation; however, with such extensive clot burden, the patient was started on a heparin drip. Four days later, he sustained a cardiac arrest secondary to venous thromboembolism. Upon achieving return of spontaneous circulation, he was taken for left heart catheterization, which revealed severe triple-vessel disease. Cardiothoracic surgery was consulted, but it was determined that the patient to be too high risk to undergo coronary artery bypass graft or operative thrombectomy. Ultimately, his clinical status deteriorated, and the patient along with family proceeded with comfort measures.SARS-CoV-2 infection primarily affects the lower respiratory tract, but there are reports of COVID-19–induced cardiac complications, including acute coronary syndromes, arrythmias, myocarditis, and thrombosis.1 Venous thromboembolism is reported to occur in approximately 30% of patients with COVID-19, but intracardiac thrombus in very rare.2 Cardiac thrombus should be considered in the diagnosis of COVID-19 in patients presenting with chest pain and leg swelling.

EFFECT OF SEVERITY OF ISCHEMIA ON QT DISPERSION IN PATIENTS WITH CORONARY ARTERY DISEASE

Background: Coronary artery disease (CAD) is the most prevalent cause of death due to myocardial ischemia. QT dispersion is a marker of increased risk for myocardial ischemia events. The objective of this study was to find out the effect of severity of ischemia on ventricular repolarization heterogeneity by measuring and comparing QT dispersion in single, double and triple coronary artery disease patients. Methods: This cross-sectional comparative study was conducted in the Department of Physiology, Army Medical College (AMC) in collaboration with Electrophysiology Department, Armed Forces Institute of Cardiology (AFIC). Forty patients aged 55±8 Yrs with CAD were included in the study. Holter monitors were used to attain ECG recordings digitally with ten electrodes. For exploration of digital QT dispersion data CardioScan Luxury version was used. Results: Out of 40 patients 18 (45%) had single, 16 (40%) double, and 6 (15%) had triple vessel disease. A significant difference was noted on comparison across mean values of QT dispersion in three groups with single, double and triple vessels coronary artery disease (p=0.01). There was also a remarkable difference of QT dispersion between single and triple vessel disease patients (p=0.007). Conclusion: Ventricular repolarization heterogeneity increases with the ischemia. Patients with triple vessel disease are more prone to risk of developing life threatening arrhythmias. Pak J Physiol 2022;18(4):11-3

Frequency of Left Anterior Descending Artery Involvement as a Culprit Vessel in Young Patient with ST Elevation Myocardial Infarction

Objective: To determine the frequency of left anterior descending artery involvement as a culprit vessel in young patient with ST elevation myocardial infarction (STEMI) at tertiary care hospital. Study Design: A cross-sectional study. Place and Duration: The Department of Cardiology, “National Institute of Cardiovascular Diseases, Karachi” Pakistan from October 2019 to April 2020. Methodology: Patients of both genders aged 25-45 years who were presented with onset of chest pain for more than 30 minutes with STEMI were included. All patients were clinically evaluated after detailed history. Routine biochemistry investigations were asked and ECG and echocardiography were performed. Frequency of left anterior descending artery involvement in patients with STEMI was noted. Results: In a total of 191 patients, mean age was 33.6±6.7 years while mean duration of chest pain was 42.5±8.3 minutes. There were 135 (70.7%) male and 56 (29.3%) female cases. In distribution of vessel disease, 76 (39.8%) had single vessel disease (SVD), 37 (19.37%) had double vessel disease (DVD) while 78 (40.84%) had triple vessel disease (TVD). Left anterior descending artery found to be positive in 88 (46.1%) patients. Practical Implications: To reduce the complications of STEMI, it is very important to increase the awareness and proper knowledge in the general public. Conclusion: Involvement of left anterior descending artery as a culprit vessel was fairly common in young patient with ST elevation myocardial infarction. Keywords: Left anterior descending artery, culprit vessel, ST elevation myocardial infarction, coronary artery disease

Role of Various Pre Operative Risk Factors in Outcome Following Coronary Artery Bypass Graft: An Institutional Based Study

Background: Coronary Artery Bypass Graft (CABG) is done in patient with Coronary Artery Disease (CAD) with Normal or decreased Left Ventricular Ejection Fraction (LVEF). Most of the patient with CAD presents with NYHA class II or III.&#x0D; Methods: It’s an analytical study of retrospectively collected data of all patients who underwent CABG for CAD. Data were collected over the period of about 30 months at Nobel Medical College and Teaching Hospital.&#x0D; Results: There were a total of 54 patients in our study. There was male 38 (72%) predominance. There were 49 (92.5%) cases having BMI &lt;30 kg/m2. However only 2 (4%) had COAD, 23 (43%) had DM II, 9 (17%) had abnormal thyroid function, 6 (11%) were dyslipidemic and 1 (2 %) had a prior history of CVA. There were 23 (4%) of patients who had history of MI in past and around 45 (85%) had Triple Vessel Disease (TVD).&#x0D; Conclusion: Among all the pre-operative risk factors HTN and H/O MI had a significant association in improvement in LVEF, similarly thyroid status had a strong association with improvement in NYHA

Correlation of Sum of ST Segment Depression in Leads V1 to V4 in Acute Inferior Myocardial Infarction with Angiographic Severity of Coronary Artery Disease

Background: Inferior wall acute myocardial infarction accounts for 40 to 50% of all acute STEMI. Patients of acute inferior myocardial infarction with ST depression in lateral leads often have greater incidence of triple vessel disease and proximal RCA lesion but in case of patients of acute inferior myocardial infarction with ST depression in precordial leads (leads V1 to V4), is a subject of determination whether it is associated with more sever coronary artery disease. The aim of this study is to determine the association of sum of ST depression in precordial leads with the probability of concomitant severity of coronary artery disease in patients with acute inferior STEMI. Methods: this cross sectional observational study was done at National institute of cardiovascular diseases (NICVD), Dhaka, Bangladesh. Total 90 patients of acute inferior myocardial infarction with precordial lead ST depression admitted at CCU within 12 hours of onset of chest pain were the study population. They were divided in two groups on the basis of sum of ST depression in precordial leads (Sum of ST depression d”4mm and &gt;4mm), 36 patients in group I and 54 patients in group II. Coronary angiography was performed during the index hospitalization period. Gensini score and Reardon score were measured. Results: Overwhelming majority of the patients was male (83.3% and 90.7%) with mean age of 51.0±9.7 and 51.0±9.9 years in group I and II respectively. Smoking, hypertension and diabetes mellitus were the most frequent risk factors in both groups. Serum troponin level was significantly high in group II (6.2±2.2 vs. 13.6±17.7, p &lt;0.05). Sum of ST depression in precordial leads was 2.84±0.66 and 7.53±3.51 in group I and group II respectively, and was statistically significant. Consideration of mean of ST depression in individual leads shows significantly higher mean in leads V2, V3 and V4 among group II patients. SVD was more frequent in group I but group II patients had higher statistically significant incidence of DVD and TVD. Gensini score (20.26±13.0 vs. 36.98±16.9) and Reardon score (4.63±2.2 vs. 6.83±2.2) was high in group II patients. Positive correlation had been depicted between summation value of ST segment depression with that of Gensini score &amp; Reardon score (Gensini score r=0.61 and Reardon score r= 0.52). Conclusion: Involvement Triple vessel and double vessel disease was remarkably higher with increasing sum of ST segment depression in precordial leads. The severity of ST segment depression in terms of summation of ST depression in leads V1 to V4 is directly proportional to the extent and severity of coronary artery disease. Bangladesh Heart Journal 2022; 37(2): 116-121