Publications by authors named "Jahanzeb Malik"

32 Publications

Thyroid function analysis in COVID-19: A retrospective study from a single center.

PLoS One 2021 30;16(3):e0249421. Epub 2021 Mar 30.

Department of Cardiology, Pakistan Institute of Medical Sciences, Islamabad, Pakistan.

Background And Objective: Coronavirus disease 2019 (COVID-19) is an on-going epidemic with a multitude of long-ranging effects on the physiological balance of the human body. It can cause several effects on thyroid functions as well. We aimed to assess the lasting sequelae of COVID-19 on thyroid hormone and the clinical course of the disease as a result.

Methods: Out of 76 patients, 48 patients of COVID-19 positive and 28 patients of COVID-19 negative polymerase chain reaction (PCR) were assessed for thyroid functions, IL-6, and Procalcitonin between moderate, severe, and critical pneumonia on HRCT.

Results: Seventy-five percent of patients with COVID-19 had thyroid abnormalities and higher IL-6 levels (76.10 ± 82.35 vs. 6.99 ± 3.99, 95% CI 52.18-100.01, P-value <0.01). Logistic regression analysis suggested TT3 (P-value 0.01), IL-6 (P-value <0.01), and Procalcitonin (P-value 0.03) as independent risk factors for COVID-19. ROC curve demonstrated IL-6 as the most sensitive marker (P-value <0.01), and TT3, and Procalcitonin as the predictor for COVID-19 disease.

Conclusion: This pilot study from Pakistan demonstrates that changes in serum TSH and TT3 levels may be important manifestations of the courses of COVID-19 pneumonia.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0249421PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8009384PMC
April 2021

A Case of Elephantiasis Nostras Verrucosa Secondary to Lymphedema Praecox Complicated by Congestive Cardiac Failure.

Am J Case Rep 2021 Mar 14;22:e930269. Epub 2021 Mar 14.

Department of Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, Pakistan.

BACKGROUND In lymphedema, an imbalance in the formation and absorption of lymph causes accumulation of protein-rich fluid in the interstitium of the most gravity-dependent parts of the body. Diagnosis is usually made based on patient medical history and a physical examination showing a typical appearance of the affected body part. Differential diagnosis is confirmed by imaging. CASE REPORT Primary lymphedema is inherited in through an autosomal dominant pattern. Congestive cardiac failure and non-filarial infections predispose patients to the secondary form of lymphedema, elephantiasis nostras verrucosa (ENV). We present the case of a 65-year-old man with lymphedema praecox complicated by congestive cardiac failure. The patient was experiencing worsening left leg swelling and had a prior history of unilateral leg swelling at puberty. The condition was inherited through an autosomal dominant pattern, as his father, elder brother, and nephew were diagnosed with the same disease. The left leg showed non-pitting edema with indurated, woody skin and lichenification. The right leg had mild pitting edema. There were numerous verrucous folds and cobblestone-like nodules, and plaques and a painless ulcer on the left leg. Laboratory evaluation demonstrated an elevated B-type natriuretic peptide. He was treated with compression stockings and inelastic multi-layer bandaging and was administered limb decongestive treatment. After 1 week of therapy, his swelling had somewhat improved. CONCLUSIONS Various conditions can cause ENV and it can superimpose on any form of hereditary lymphedema. The most effective strategy for this condition seems to be a thorough workup of the underlying cause of the ENV and early intervention.
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http://dx.doi.org/10.12659/AJCR.930269DOI Listing
March 2021

Pierre Robin sequence with tetralogy of Fallot: An unusual finding.

Int J Health Sci (Qassim) 2021 Mar-Apr;15(2):58-60

Department of Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, Pakistan.

Pierre Robin sequence has been known to present with multiple somatic abnormalities. It is known that the syndrome impairs cardiogenesis. However, the reason for this is unknown. Impaired cardiogenesis manifests in the form of various defects such as ventricular septal defect and atrial septal defect but the presence of tetralogy of Fallot is very rare.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7934134PMC
March 2021

Fondaparinux-associated Thrombocytopenia.

Pak J Med Sci 2021 Mar-Apr;37(2):598-599

Dr. Matiullah Kamin, Shifa International Hospital, Islamabad, Pakistan.

Heparin-induced thrombocytopenia (HIT) is an immune-mediated condition causing thrombocytopenia and paradoxical thrombosis after exposure to heparin or low-molecular-weight heparin. It has been rarely reported by Fondaparinux, an artificial pentasaccharide similar to heparin. This manuscript presents a case of HIT associated with fondaparinux use.
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http://dx.doi.org/10.12669/pjms.37.2.3522DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7931326PMC
March 2021

Management of Spontaneous Chylothorax in a Neonate: A Medical Challenge.

Cureus 2021 Jan 27;13(1):e12942. Epub 2021 Jan 27.

Internal Medicine, College of Physician and Surgeons Pakistan, Peshawar, PAK.

Chylothorax or collection of lymphatic fluid in the pleural space is an exceedingly rare cause of pleural effusion and respiratory distress in neonates. In adults, prompt diagnosis and effective treatment regimen can aid in the resolution of chylothorax; however, in neonates treating the condition can be an onerous challenge for the pediatricians due to the rarity and perplexing clinical presentation. We elucidate a case of spontaneous chylothorax in a 15-day-old neonate who presented to us with respiratory distress, chest indrawing, and cyanosis for nine days. The prenatal and birth history of the patient were insignificant. The detailed laboratory and radiological assessment of the patient divulged a diagnosis of spontaneous chylothorax for which the patient was intubated. Unfortunately, the patient deteriorated and eventually expired on the 23rd postnatal day due to the complications of respiratory acidosis and hypoxemia.
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http://dx.doi.org/10.7759/cureus.12942DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920235PMC
January 2021

Coronary Artery Calcium Score: Assessment of SYNTAX Score and Prediction of Coronary Artery Disease.

Cureus 2021 Jan 14;13(1):e12704. Epub 2021 Jan 14.

Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK.

Background With the advent of modern imaging technologies, non-invasive assessment of the coronary system is not only possible but its complexity and plaque burden can be quantified. This study aims to determine whether calcium score on computed tomography coronary angiography (CTCA) can be associated with the complexity of coronary artery disease (CAD), which is determined by the SYNTAX score on coronary angiography, as well as to determine which cut-off value of coronary artery calcium (CAC) score can predict severe CAD in our population. Methodology This was a cross-sectional study conducted at the Rawalpindi Institute of Cardiology, Pakistan from January 2019 to March 2020. The calcium score of all patients with low-to-intermediate pretest probability of CAD was calculated on CTCA. All patients who had significant disease on CTCA were subjected to conventional coronary angiography and SYNTAX score was calculated, which was later used to determine the association between calcium and SYNTAX score. Results A total of 90 patients were included in the study. CAC and SYNTAX score were found to be positively correlated (Pearson coefficient [r] = 0.354; p = 0.001). The total CAC score with a cut-off value of 212 recognized patients with the SYNTAX score of >27. The sensitivity was 66.7% and specificity was 70.5% with an area under the curve of 0.743. The mean calcium score of patients in our study group was 223, with the maximum score of 1,216 and the minimum score of zero. Conclusion A CAC score greater than 212 is associated with a high SYNTAX score indicating complex disease. Only age is an independent predictor of calcium score.
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http://dx.doi.org/10.7759/cureus.12704DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7883584PMC
January 2021

Genetic Warfarin-Resistance Resulting in Surgery to Change a Prosthetic Valve.

Eur J Case Rep Intern Med 2020 5;7(11):001851. Epub 2020 Aug 5.

Rawalpindi Institute of Cardiology, Rawal Road, Rawalpindi, Pakistan.

Warfarin is a readily available anticoagulant used worldwide in a variety of clinical scenarios. Patients who need more than 15 mg/day are considered to be warfarin resistant. Numerous genes have been implicated in warfarin pharmacogenetics, with genes encoding CYP2C9 and VKORC1 shown to be the most important determinants of drug dosage requirements. A 27-year-old woman was admitted as she had a sub-therapeutic international normalized ratio (INR) after prosthetic mitral valve replacement. Even after a warfarin dose of 50 mg/day, her INR was not in the therapeutic range, so the heart team decided to replace her metallic valve with a bioprosthetic valve, thus alleviating the need for anticoagulation.

Learning Points: Genetic warfarin resistance is rare and mainly associated with two genes encoding CYP2C9 and VKORC1.In addition to dietary counselling and drug compliance, options in warfarin-resistant patients include increasing the warfarin dose, which carries a risk of bleeding complications, or switching to novel oral anticoagulants, which increases the risk of prosthetic valve thrombosis.We replaced a metallic valve with a bioprosthetic valve, which is the first time this has been documented in a patient with warfarin resistance.
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http://dx.doi.org/10.12890/2020_001851DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7654999PMC
August 2020

Elevated D-Dimers and Right Ventricular Dysfunction on Echocardiography for Diagnosis of Pulmonary Embolism: A Validation Study.

Cureus 2020 Oct 3;12(10):e10778. Epub 2020 Oct 3.

Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK.

Background There is an increasing need to explore other non-invasive techniques for the diagnosis of pulmonary embolism in resource-limited countries. Objective To assess the validity of elevated D-dimer levels and right ventricular (RV) dysfunction on echocardiography in predicting definite massive pulmonary embolism among patients diagnosed with massive pulmonary embolism using computed tomography (CT) pulmonary angiography as the gold standard. Methods The patients with acute massive pulmonary embolism on CT pulmonary angiography were included. The participants underwent 12-lead electrocardiography, assessment of D-dimer levels, and bedside echocardiography to determine right ventricular dysfunction. The data were recorded on a proforma and analyzed using IBM SPSS software version 26.0 (IBM Corp., Armonk, NY). Results There were 160 patients in the study. The mean age was 49.19 ± 14.89 years. Elevated D-dimer levels were seen in 80.60% of the patients whereas ventricular dysfunction on echocardiography was seen in 90.00% of the patients. The sensitivity and specificity of elevated D dimer levels were 78.99% and 14.60%, respectively. The positive predictive values (PPV) and negative predictive values (NPV) for elevated D-dimer levels were 72.87% and 19.35%, respectively. In contrast, the sensitivity of ventricular dysfunction was 94.96% and specificity 24.39%. PPV was found to be 78.47% and NPV was 62.50%. Conclusion Positive D-dimer levels and ventricular dysfunction on echocardiography are sensitive enough to consider the diagnosis of massive pulmonary embolism but lack adequate specificity, thus, necessitating the presence of other noninvasive tests.
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http://dx.doi.org/10.7759/cureus.10778DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7606195PMC
October 2020

Eosinopenia in Patients With Typhoid Fever: A Case-Control Study.

Cureus 2020 Sep 10;12(9):e10359. Epub 2020 Sep 10.

Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK.

Background and objectives Salmonella typhi is involved in one of the most prevalent infectious diseases of South East Asia, typhoid fever, but diagnostic tests cannot be performed regularly in developing countries. The objective of the study is to determine the association of eosinopenia with culture or serology-proven typhoid fever in patients, to determine the association of leukopenia with culture or serology-proven typhoid fever in patients and to determine independent predictors of eosinopenia. Methods This case-control study, done at Fauji Foundation Hospital, Pakistan, included patients with symptoms suggestive of typhoid fever, culture, or serology positive for typhoid fever and excluded patients who had been previously diagnosed with malaria and dengue hemorrhagic fever. After flagging cultures and serology, the records were viewed for leukocyte counts. Data, including age, gender, and clinical symptoms, were also recorded for analysis. Results Out of 200 participants, 59 participants with diagnosed typhoid fever had eosinopenia. There were 29 participants who had been diagnosed with typhoid fever via culture or serology and had leukopenia. Eosinopenia and leukopenia were more likely to be present in patients with a diagnosis of typhoid (OR: 9.60, 20.00). The independent predictors for eosinopenia were DOT enzyme immunoassay (DOT EIA) positive for Salmonella typhi, culture positive for Salmonella typhi and leukopenia (p<0.05). Conclusion The presence of eosinopenia and features or serology suggestive of typhoid would most likely be associated with cultures being positive and, therefore, might provide an efficient means to begin treatment.
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http://dx.doi.org/10.7759/cureus.10359DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7549842PMC
September 2020

Induction of Combination Therapy for the Management of Hepatitis C: An Observational Study.

Cureus 2020 Sep 5;12(9):e10259. Epub 2020 Sep 5.

Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK.

Background and objective Hepatitis C infection is prevalent in Pakistan. The purpose of this study was to observe the therapeutic effects of conventional interferon in combination with ribavirin among treatment-naive hepatitis C patients. Methods This descriptive cross-sectional study of hepatitis C combination therapy was conducted at our institute after approval. All the patients received treatment with conventional interferon (5-MU three times weekly) and ribavirin (1000mg/day) for four weeks. A follow-up for the rapid virological response (RVR) was done in the fourth week of treatment.  Results The mean age of the patients was 37.43. There was a gradual decrease in RVR with increasing age after four weeks of treatment.  Conclusion The combination therapy showed good RVR in the fourth week among all hepatitis C patients.
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http://dx.doi.org/10.7759/cureus.10259DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7536117PMC
September 2020

Optical coherence tomography: assessment of coronary artery disease and guide to percutaneous coronary intervention.

Scott Med J 2021 Feb 4;66(1):29-33. Epub 2020 Oct 4.

Trainee, Department of Cardiology, Rawalpindi Institute of Cardiology, Pakistan.

Background And Aims: Angiographic guidance for percutaneous coronary intervention (PCI) has significant limitations in interpretation. The superior spatial resolution of optical coherence tomography (OCT) can provide meaningful clinical benefits, although limited data is available on Asian populations. This study aimed to determine whether OCT can provide additional advantages and useful clinical information beyond that obtained by angiography alone in decision making for PCI.

Methods: This was an observational study based on a single tertiary cardiac center in Pakistan, which includes 67 patients who underwent coronary angiogram and stenting. Their pre and post stenting OCT findings were recorded. Any additional intervention was also recorded. The data were analysed using IBM SPSS software version 26.0.

Results: The mean age was 55.00 ± 9.00 years. Majority of the patients were males (65.7%). On angiography, there was an equal number of stable and ruptured plaques (38.8%). Post stenting results showed 29.9% under deployed stents and 34.3% were either undersized or mal-apposed. Out of 67 patients, 50 (74.6%) needed re-intervention after PCI. Among different procedures, post-dilatation was most common.

Conclusion: The main OCT benefit is in borderline lesions on CA, in whom OCT identifies significant coronary stenosis and leads to PCI indication in patients. In the post-PCI context, OCT leads to an indication of PCI optimisation in half of the coronary lesions.
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http://dx.doi.org/10.1177/0036933020961182DOI Listing
February 2021

Impact of Primary Percutaneous Coronary Intervention on Complete Atrioventricular Block With Acute Inferior ST-Elevation Myocardial Infarction.

Cureus 2020 Aug 25;12(8):e10013. Epub 2020 Aug 25.

Paediatrics and Child Health, Aukland City Hospital, Aukland, NZL.

Background and aims Complete atrioventricular block (CAVB) is associated with poor clinical outcomes in ST-elevation myocardial infarction (STEMI). This study determined the frequency and outcomes of primary percutaneous coronary intervention (PPCI) in patients with CAVB with acute inferior STEMI. Methods We conducted an observational, prospective study and enrolled 151 patients who were diagnosed with inferior STEMI. All patients received PPCI. The clinical outcomes were compared in patients with and without CAVB. The data was recorded on a collection form and analyzed on Statistical Package for Social Sciences (SPSS) software. Descriptive statistics were applied. For quantitative variables, standard deviation and mean were obtained, and statistical tests were also applied. Results Baseline characteristics were homogeneous in all patients. Half of the study population was either diabetic or hypertensive. Out of 151 participants, 21 (13.9%) developed CAVB. Two-thirds of the patients, who had developed heart block, reverted after PPCI. After a follow-up of two weeks, in-hospital mortality did not differ between the groups. Conclusion We conclude that PPCI can improve outcomes of CAVB-complicated acute inferior STEMI and suggest that primary PCI should be the preferred reperfusion therapy in patients with CAVB with STEMI.
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http://dx.doi.org/10.7759/cureus.10013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7515546PMC
August 2020

Dual right coronary artery: an unconventional presentation from Pakistan.

Pan Afr Med J 2020 28;36:221. Epub 2020 Jul 28.

Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan.

There is a significant variation in the mapping of epicardial coronary arteries. This variation may present as different anomalies. These anomalies are usually asymptomatic and can be present at birth. Some might become symptomatic during adulthood and subsequently, result in sudden death. The anomalies, in turn, present a challenge to clinicians during therapeutic intervention. Therefore, there is a growing need to have knowledge about the various forms of the coronary artery anomalies. In our case report, we present the case of a patient who had one such anomaly and provide a hint at one strategy that was used to tackle the challenge.
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http://dx.doi.org/10.11604/pamj.2020.36.221.21307DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7490145PMC
December 2020

Causality of Chronic Suppurative Otitis Media: An Observational Study.

Cureus 2020 Aug 18;12(8):e9832. Epub 2020 Aug 18.

Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK.

Objective Chronic otorrhoea is a disease of the ear that lasts for more than 6-12 weeks, through a perforated tympanic membrane. We sought to determine the cause of chronic suppurative otitis media (CSOM) at our institute. Methodology Ear swabs taken from enrolled patients (n=139) were sent for culture and sensitivity. Statistical analysis was done using Statistical Package for Social Sciences (SPSS), version 26 (IBM Corp., Armonk, NY) Results Common pathogenic bacteria in chronic otitis media observed were Pseudomonas aeruginosa 81 (58%) while Klebsiella pneumoniae was found in 58 (42%) of cases. Conclusion We concluded that Pseudomonas aeruginosa was the most common causative agent of CSOM at our institute.
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http://dx.doi.org/10.7759/cureus.9832DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7496497PMC
August 2020

Finders Keepers: A Case of the Rogue Pacing Wire.

Cureus 2020 Aug 17;12(8):e9823. Epub 2020 Aug 17.

Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK.

We report a middle-aged woman with frequent episodes of pre-syncope due to complete heart block. She had no previous history of anticoagulation or steroid therapy, and underwent temporary pacemaker insertion. In spite of only mild symptoms, she was found to have a right ventricle perforation on CT. After placement of permanent lead, the patient was discharged home in a stable condition with no further complaints on follow-up.
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http://dx.doi.org/10.7759/cureus.9823DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7495961PMC
August 2020

Paying in Blood: A Case of Thrombocytopenia in Covid-19.

Cureus 2020 Aug 16;12(8):e9791. Epub 2020 Aug 16.

Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK.

Novel coronavirus disease 2019 (COVID-19) primarily involves the respiratory system. Consumptive coagulopathy is seen in acute respiratory distress syndrome (ARDS) and multi-organ failure (MOF). Usually, only severely sick patients develop mild thrombocytopenia. We present a case of mildly symptomatic young adult, presenting with severe thrombocytopenia. She responded well to corticosteroids.
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http://dx.doi.org/10.7759/cureus.9791DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7491688PMC
August 2020

Imaging in Breast Cancer: Use of Magnetic Resonance Spectroscopy.

Cureus 2020 Aug 14;12(8):e9734. Epub 2020 Aug 14.

Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK.

Background: Magnetic resonance spectroscopy (MRS) is used nowadays with increased specificity to distinguish between malignant and benign breast lesions.  Objective: To determine the diagnostic accuracy of MRS in malignant breast lesions.  Methodology: Newly diagnosed patients (n=158) having breast lesions diagnosed on ultrasound and mammography were enrolled to conduct the present study at Bahawal Victoria Hospital, Bahawalpur, Pakistan for six months. Enrolled patients were informed and consent was taken. Every patient underwent proton MRS using a 1.5 Tesla MR system. Fast scans in various planes were obtained. Mean ± standard deviation (SD) was given for age, size of the lump, and duration of the disease whereas frequency and percentage were given for benign and malignant breast lesions by SPSS version 26. A significant p-value was ≤0.05.  Results: The mean age of patients was 41.27 ± 5.48 years. The diagnosis of malignant breast lesions in 80 (50.63%) patients was shown by MRS whereas histopathology showed malignancy in 83 (52.53%) cases.  Conclusion: MRS is an accurate diagnostic modality for malignant breast lesions.
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http://dx.doi.org/10.7759/cureus.9734DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489784PMC
August 2020

A Widow-Maker and a Doppelganger: An Anomalous Case of the Coronaries.

Cureus 2020 Aug 7;12(8):e9603. Epub 2020 Aug 7.

Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK.

The anomalous origin of the left circumflex (LCX) artery from the right coronary sinus is a relatively rare condition. A 'double' left anterior descending (LAD) artery is probably the rarest of coronary artery anomalies. We present a case of acute myocardial infarction with a clot and a critical distal stenosis in the left main stem (LMS) supplying a dual LAD and an aberrant origin of the LCX.
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http://dx.doi.org/10.7759/cureus.9603DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7478500PMC
August 2020

Modern Lipid Management: A Literature Review.

Cureus 2020 Jul 24;12(7):e9375. Epub 2020 Jul 24.

Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK.

Pro-protein convertase subtilisin/Kexin type 9 (PCSK9) inhibitors are relatively new, non-statin, lipid-lowering drugs that reduce low-density lipoprotein cholesterol (LDL-C) by 60%. PCSK9 inhibitors reduce the blood concentrations of cholesterol by the degradation of LDL receptors, which subsequently extracts cholesterol from cells. This leads to cardiovascular risk reduction in various at-risk populations, including atherosclerotic coronary artery disease. Despite their promise for advanced lipid-lowering ability, cost-effectiveness is a barrier to their routine use. While searching PubMed, we extracted land-mark trials on two of the anti-PCSK9 monoclonal antibodies, alirocumab and evolocumab. When combined with statins or ezetimibe, they show an exponential fall in LDL-C levels, helping achieve target values in high-risk populations and decreasing cardiovascular adverse events. Ongoing research is exploring the long-term efficacy of these antibodies in established coronary artery disease and familial hypercholesterolemia with more prospects for this novel lipid-lowering therapy.
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http://dx.doi.org/10.7759/cureus.9375DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7444996PMC
July 2020

COVID-19 Associated Pneumonia and Pleural Effusion Masquerading as Heart Failure in Rheumatic Heart Disease.

Eur J Case Rep Intern Med 2020 10;7(8):001842. Epub 2020 Jul 10.

Rawalpindi Institute of Cardiology, Rawal Road, Rawalpindi, Pakistan.

The ongoing outbreak of coronavirus disease 2019 (COVID-19) that began in Wuhan, China, became an international emergency when thousands of people were infected around the world. COVID-19 emerged in Pakistan in April 2020, precipitating a nationwide lockdown. While some countries are now recovering from the pandemic, its peak is not estimated to occur in Pakistan until August 2020. We present a case of rheumatic heart disease with fever, myalgia and an unusual radiological finding of the virus.

Learning Points: Unusual radiological findings are being seen in COVID-19 patients.Pleural effusion in a mildly symptomatic patient is a rare presentation of the disease.Early aggressive treatment can produce dramatic improvement in COVID-19 pneumonia.
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http://dx.doi.org/10.12890/2020_001842DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7417058PMC
July 2020

Frequency of Mucositis Among Head and Neck Cancer Patients Receiving Three-Dimensional (3D) Radiotherapy.

Cureus 2020 Jul 9;12(7):e9089. Epub 2020 Jul 9.

Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK.

Background and objective Head and neck cancer can arise from any site like hypo-pharynx, oro-pharynx, lip, oral cavity, or larynx. Almost 90% of them are head and neck squamous cell carcinomas (HNSCC). In the current project, the goal was to determine the frequency of acute side effects in terms of mucositis during and immediately post-irradiation period in patients receiving concurrent three-dimensional (3D) radiotherapy in a tertiary care hospital.  Methodology This descriptive case series with 106 enrolled patients was carried out from December 2019 to May 2020 at the Department of Radiation Oncology following approval. All patients were given radiotherapy or chemo-radio-therapy as per the clinician's advice and hospital protocol. All patients were evaluated at pre radiation time, at weekly intervals during treatment and at 11 weeks from 1st radiation fraction. Data was entered and analyzed by Statistical Package for Social Sciences, version 20 (SPSS Inc., Chicago, IL). Chi-square and Fisher's exact test was applied as p-value ≤ 0.05 was considered significant.  Results In the present study, all patients (n=106) showed a mean age of 57.8 ± 8.3 years. There was a gradual increase in grades of mucositis in all patients after treatments until seven weeks. After one month of post-treatment, a decrease in grades of mucositis was observed in all patients.  Conclusion Acute side effects appeared in all patients receiving 3D radiation therapy (RT) although the treatment response was good. Hence, we concluded it has a high incidence of treatment-related toxicities but it is safe.
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http://dx.doi.org/10.7759/cureus.9089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7417032PMC
July 2020

Eosinophilic Granulomatosis With Polyangiitis (Churg-Strauss Syndrome) Mimicking a Stroke and Acute Coronary Syndrome: A Case Report.

Cureus 2020 Jul 3;12(7):e8984. Epub 2020 Jul 3.

Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK.

Churg-Strauss syndrome (CSS) is a rare disease of multiple organ involvement attributed to asthma, eosinophilia, and vasculitis as a diagnostic criterion. Here we report a case of CSS presenting with left leg weakness and chest pain with a diagnosis of myocarditis and neuropathy. Eosinophilia, history of asthma, peripheral neurological damage led to the diagnosis of CSS. Transthoracic echo showed a full-sized segmental wall motion abnormality with normal CT angiography. He responded well to steroid therapy.
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http://dx.doi.org/10.7759/cureus.8984DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7402424PMC
July 2020

Secundum Atrial Septal Defect With Early Presentation of Eisenmenger Syndrome and Right-Heart Failure: A Rare Case Report and Literature Review.

Cureus 2020 Jul 3;12(7):e8980. Epub 2020 Jul 3.

Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK.

Eisenmenger syndrome, the most advanced form of pulmonary arterial hypertension (PAH), poses a considerable risk to the survival and quality of life of patients. It is more commonly seen in large intra-cardiac defects like ventricular septal defects (VSD) or patent ductus arteriosus (PDA), and rarely in atrial septal defects (ASD). Early diagnosis is the single most important step in the definitive management of the condition; otherwise, only conservative treatment can be offered. In this report, we present the case of a 20-year-old female patient diagnosed with Eisenmenger syndrome secondary to a large secundum ASD. The patient responded well to medical treatment.
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http://dx.doi.org/10.7759/cureus.8980DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7402440PMC
July 2020

Clinical Outcomes of Mechanical Prosthetic Valve Thrombosis.

Cureus 2020 Jun 22;12(6):e8760. Epub 2020 Jun 22.

Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK.

Objective To evaluate characteristics and outcomes of patients presenting with mechanical prosthetic valve thrombosis in a tertiary cardiac center in Pakistan. Methods This was a prospective and interventional study conducted at Rawalpindi Institute of Cardiology over a period of two years. The clinical characteristics of patients presenting with clinical suspicion of prosthetic valve thrombosis were recorded. They were, then, subjected to streptokinase, redo surgery and heparin based on their hemodynamic stability, thrombus burden and surgical risk. The patients were then followed for the outcomes of the study. Results Out of 576 patients with mechanical valve replacement during the study period, 70 patients had developed prosthetic valve thrombosis. Out of 70 patients, there were 41 female (58.50%) and 29 male (41.50%) participants. The mean age of the participants was 48.40±15.00 years. The overall incidence of mechanical prosthetic valve thrombosis was 12.15%. There were 30 patients (42.80%) with a suboptimal international normalized ratio (INR) and 28 patients (40.00%) were non-compliant to warfarin therapy. The overall incidence of adverse clinical outcome was 18.00%, while the overall mortality rate was 10.00%. The mortality was higher for patients who underwent redo surgery (16.60%) as compared to patients who had received fibrinolytic therapy (9.60%). Conclusion Poor compliance with warfarin and suboptimal INR are the important factors causing mechanical prosthetic valve. Because of lower mortality rate, fibrinolysis with streptokinase is a reasonable treatment option for mechanical prosthetic valve thrombosis.
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http://dx.doi.org/10.7759/cureus.8760DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7377662PMC
June 2020

Adverse Events in Primary Percutaneous Coronary Angioplasty With Drug-Eluting Stents Compared With Drug-Coated Balloons: A Retrospective Outlook.

Cureus 2020 Jun 8;12(6):e8500. Epub 2020 Jun 8.

Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK.

Objective To compare drug-eluting stents (DES) with drug-coated balloons (DCBs) in terms of major adverse cardiovascular and cerebrovascular events (MACCE) in patients who have undergone primary percutaneous coronary intervention (PPCI). Methodology Out of 210 angioplasties in six months, 80 patients were included; 40 in DES and 40 in DCB, respectively. All had a successful PPCI. It was defined as the achievement of thrombolysis in myocardial infarction (TIMI) grade II/III with <20% residual stenosis for the DES and TIMI grade II/III with <30% residual stenosis for the DCB. Any subsequent MACCE during the ensuing six months were assessed from emergency/outpatient records during their subsequent hospital visits, hospital registry, and telephonic interviews. Results The mean age in the DES group was 54.83 + 8.72 years while it was 56.8 + 8.9 years in the DCB group. The left anterior descending artery (LAD) was the culprit artery in the majority of the cases in both groups. The mean diameter of DES and DCB was 3.17 + 0.38 mm and 2.75 + 0.53 mm, respectively. Overall, 15 adverse events were seen in the DES group and 16 in the DCB group. The difference was insignificant (P-value = ≥ 0.999). There were nine hospitalizations due to chest pain in the DES group and eight in the DCB group. Total vessel revascularization (TVR) was seen in two patients in the DES group and three patients in the DCB group. None of the patients suffered a stroke. All variables of MACCE were non-significant (P-value = ≥ 0.999). Conclusion DCB appears to be non-inferior to DES in PPCI at a median follow-up of six months.
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http://dx.doi.org/10.7759/cureus.8500DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7343313PMC
June 2020

Myocardial blush grade: a determinant of left ventricular ejection fraction and adverse outcomes in STEMI.

Scott Med J 2021 Feb 6;66(1):34-39. Epub 2020 Jul 6.

Assistant Professor, Department of Cardiology, Rawalpindi Institute of Cardiology, Pakistan.

Background And Aims: Despite restoration of blood flow, subtle microvascular obstruction can occur. This obstruction can be graded using myocardial blush grade. We aimed to investigate the role of myocardial blush grade in ejection fraction and adverse outcomes, after percutaneous intervention.

Methods: A prospective, observational study was conducted at our institute with a calculated sample size. Variables such as age, gender, and ejection fraction were noted before the intervention. The patients were followed for 3 months to determine the outcomes. The data was analyzed using IBM SPSS software version 26.0. P-value of less than 0.05 was considered significant for the statistical tests.

Results: There were 74 male and 36 female participants in the study. The mean age was 52.20 ± 10.02 years. The most common adverse outcome was heart failure (18%). There was a significant Pearson's correlation between myocardial blush grade and improvement in ejection fraction (p < 0.05). Improvement in myocardial blush grade was significantly related to a decrease in adverse outcomes (p < 0.05). Regression analysis proved myocardial blush grade and diabetes status as independent predictors of percentage increase in ejection fraction (p < 0.05).

Conclusion: High myocardial blush grade is one of the independent predictors of better outcomes in ST-elevation myocardial infarction.
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http://dx.doi.org/10.1177/0036933020941260DOI Listing
February 2021

Is There a Role for Colchicine in Acute Coronary Syndromes? A Literature Review.

Cureus 2020 May 17;12(5):e8166. Epub 2020 May 17.

Pharmacology, Lahore Medical and Dental College, Lahore, PAK.

Inflammation is identified as a keystone of atherosclerosis. This review of the literature explores the unique anti-inflammatory effects of colchicine and summarizes the mechanisms of inflammation in acute coronary syndrome. It outlines other therapeutic strategies employed until now to target coronary inflammation and analyzes the role of colchicine in improving the outcomes of acute coronary syndrome. Despite the existence of guideline-directed medical therapy, there still remains a higher risk for recurrence due to continuous inflammation at remaining vascular sites. Several anti-inflammatory strategies have been employed, but they have not been shown to be beneficial. However, colchicine is becoming increasingly popular in tackling this problem. For this review, databases were searched for trials on the role of colchicine as an anti-inflammatory therapy in acute coronary syndrome.
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http://dx.doi.org/10.7759/cureus.8166DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7296886PMC
May 2020

Microbial Resistance in Urinary Tract Infections.

Cureus 2020 May 14;12(5):e8110. Epub 2020 May 14.

Internal Medicine, Benazir Bhutto Hospital Rawalpindi, Rawalpindi, PAK.

Objective To determine the pattern of microbes responsible for urinary tract infections and their susceptibility to antimicrobial agents. Methods This was a prospective, observational study conducted at Benazir Bhutto Hospital, Rawalpindi, Pakistan. The urine samples of 440 patients were collected and sent for culture and sensitivity analysis. The results were recorded on a proforma. The data were analyzed using IBM Statistical Package for Social Sciences (SPSS) version 22 (IBM Corp., Armonk, NY). Descriptive statistics were used to describe the data. Chi-square test was applied to determine the significance of the difference between gender and microorganisms as well as microorganism and antimicrobial sensitivity. P-value of less than 0.05 was considered significant. Results Out of 440 urine samples, 144 culture-positive samples had been obtained from male participants and 296 culture-positive samples had been obtained from female participants. The most common organism on analysis was Escherichia coli. There were more rates of resistance in males. The organisms were most susceptible to fosfomycin and imipenem (p = 0.01). The organisms were resistant to ceftazidime (p = 0.01). Conclusion In Pakistan, most patients with resistance present with mild symptoms instead of severe clinical manifestations. Therefore, there is a need to reduce the over-prescription of antibiotics for urinary tract infections, especially in cases when other non-antimicrobial agents can be used.
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http://dx.doi.org/10.7759/cureus.8110DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7292691PMC
May 2020