Nepalese Heart Journal

Patient blood management for cardiovascular surgery: Clinical practice consensus statement

Sun, 05 Nov 2023 00:00:00 +0000

Anemia, blood loss and transfusion related issues following cardiovascular surgery are detrimental to patient outcomes. This document provides a concise overview of the Patient Blood Management for Cardiovascular Surgical Practice in Nepal. The consensus aims to optimize patient outcomes and enhance the quality of care in cardiovascular surgery by emphasizing evidence-based approaches to blood management. The document covers a range of topics, including preoperative assessment, intraoperative strategies, and postoperative care, with a focus on minimizing unnecessary blood transfusions, promoting hemostasis, and reducing the risk of complications. By adhering to this consensus, healthcare professionals can contribute to improved patient safety and overall clinical effectiveness in the field of cardiovascular surgery.

Screening for Hypertension in Asymptomatic Individuals in Nepal: An Expert Consensus Statement

Sun, 05 Nov 2023 00:00:00 +0000

Hypertension affects a substantial proportion of the general population in Nepal with prevalence ranging from 20 to 30 percent. Early diagnosis and treatment are essential for undiagnosed hypertension and is possible through hypertension screening. The aim of this paper is to provide unified consensus recommendations for the effective screening of hypertension in Nepal. In two National Advisory expert consensus meetings, a total of 42 experts participated, discussed and voted on the key statements for formulating the consensus. Each key statement was scored on a Likert scale ranging from 1 to 9 and a mean score was calculated. The consensus statement was accepted if the mean score was seven or more with the voting of more than two-thirds of the experts. The main consensus recommendations are the following. First, screening for hypertension should start among adults from 18 years of age. Second, effective screening of hypertension can aid in the early diagnosis, control, and improve the cardiovascular disease outcomes. Third, in asymptomatic adults, re-screening is necessary every 3 to 6 months and every 3 to 5 years for initial blood pressure levels of 130-139/80-89 mmHg and <130/85 mmHg, respectively. Fourth, hypertension screening is cost-effective in a resource-limited setting. The use of consensus recommendations will help in a unified community screening of hypertension among the asymptomatic adult population of Nepal. Screening of hypertension should be promoted by all the stakeholders in healthcare services.

A Randomized Comparison of Two Doses of Tranexamic Acid in High-Risk Open-Heart Surgery

Sun, 05 Nov 2023 00:00:00 +0000

Background and aims: Tranexamic acid is commonly used in cardiac surgery to minimize perioperative bleeding. There are wide variations in dose of this drug. This study aims to find out the minimal effective dose of tranexamic acid.

Methods: Patients were randomized into low dose group receiving 10 mg/kg and high dose group receiving 30 mg/kg bolus of tranexamic acid each followed by an infusion of 1mg/kg/hr until the end of surgery. Primary objective was to compare blood loss during the first postoperative day. Secondary objectives were to compare total blood products transfused during 24 hours post-operative period, to compare the incidence of re-explorations and to compare the adverse drug reactions between the groups.

Results: There were sixty patients in each group. There was a signifcant difference in blood loss (435.17± 299.91 ml vs 528.64 ±254.04 ml) between the low dose group and dose group (p=0.010). Transfusion of packed red blood cell, re-exploration and adverse drug reactions were higher in high dose group however these were not statistically signifcant.

Conclusion: Higher dose of tranexamic acid is not effective in reducing blood loss in open heart surgery in first postoperative day.

Cardiovascular Disease Risk Profiling among First-Degree Relatives of Premature Coronary Artery Disease Patients

Sun, 05 Nov 2023 00:00:00 +0000

Background and Aims: First-degree relatives of patients with premature coronary artery disease are at heightened risk of cardiovascular events due to the synergy of genetic and environmental factors. The aim of this study was to assess the cardiovascular disease (CVD) risk factors and to estimate cardiovascular risk in first-degree relatives of patients with premature CAD.

Methods: The study was conducted among first-degree relatives of patients with coronary artery disease in a tertiary care hospital in Kathmandu. A total of 144 first-degree relatives aged 18 years or older participated in this study. Age and gender matched subjects with no clinical evidence of CAD and no history of premature CAD in frst degree relatives were recruited as controls. The cardiovascular risk of study participants was assessed using the American Heart Association (AHA) Cardiovascular Risk Assessment Tool.

Result: The study age group was between 18 to 59 years. The mean age of the subjects was 35.54 ± 10.57 years and 63.19% of subjects were men. A statistically significant number of first-degree relatives of premature CAD were found to be hypertensive and had metabolic syndrome. CVD risk factors like physical inactivity, smoking, diabetes, and dyslipidemia were found in 46.5%, 47.22%, 13.2%, and 52.01%, of the study participants, respectively.

Conclusion: The study highlights the widespread presence of risk factors and underlying medical conditions among young study participants both with and without a family history of premature CAD. Appropriate direction based on opportunistic screening programs and risk stratifcation should be initiated which can play an important role in the primary prevention of early CAD.

Antithrombotic Adherence to guideline-directed therapy and risk profile among Non-Valvular Atrial fibrillation patients

Sun, 05 Nov 2023 00:00:00 +0000

Introduction: Patients with Atrial fbrillation (AF) are at fivefold higher risk for Ischemic stroke than in the general population. Although the current therapeutic guidelines recommend the use of anticoagulants for thromboembolic prophylaxis in patients with nonvalvular AF (NVAF) with additional risk factor(s) for stroke, the global registry data show non-adherence to guidelines for the management of stroke in diferent regions of the world. The current study conducted at the tertiary referral cardiac center of Nepal for addressing the risk profle of stroke based on the current risk scores and the use of antithrombotic agents NVAF patients.

Methodology: This was a descriptive observational cross sectional study conducted at Shahid Gangalal National Heart Centre (SGNHC), Kathmandu, Nepal from December 2020 to June 2020 which included patients with Nonvalvular AF. The main objective of the study was to study the clinical characteristics, stroke risk profle based on CHA ₂DS₂-VaSc score and risk of bleeding based on HAS-BLED score and the patterns of use of antithrombotic agents in NVAF patients.

Results: A total of 79 cases of NVAF were included with 48(60.8%) males and 31(39.2%) females. The mean CHA₂DS₂-VaSc and HAS-BLED score were 2.44±1.2 and 1.51±1.4 respectively. The majority patients 38% had permanent AF followed by 25.5% had paroxysmal AF. Majority of patients were symptomatic with 67.1% presented with palpitation while 32.9% presented with shortness of breath (SOB). Based on the European Heart Rhythm Association (EHRA) AF related symptoms score, 41.8% had EHRA 2a and 2b while 1.3% had EHRA 4 score. The use of anticoagulants in patients with Nonvalvular AF was 41.6%, with NOACS in 33 % and warfarin used in 8.9% cases. The majority of patients 51.8% of study population were using anti-platelet agents with aspirin in 49.3 % and clopidogrel in 2.5 % cases while no medication in 6.3% of cases. Although 70.8% patients had CHA₂DS₂-VaSc score of 2 or more but the use of anticoagulants was only 58.9% with 46.4% NOACS and 12.5% using warfarin among this group of patients.

Conclusion: Although the use of anticoagulant with NOACS in patients with higher risk of stroke is increasing, it is still underused in the majority of cases .There is a need of nationwide AF registry and the need of adoption of the current recommended guidelines to increase use of Anticoagulants in patients with Nonvalvular AF patients for the prevention of stroke .

Effect of an Educational Intervention for Nursing Personnel on Emergency Inventory and Drugs Checklist of Resuscitation Trolley in a Tertiary Cardiac Center, Kathmandu.

Sun, 05 Nov 2023 00:00:00 +0000

Background and Aims: A crash cart is a trolley with emergency medicines and equipments required for medical emergencies. Nurses often witness cardiac arrest. They should be familiar with the placement of equipments and drugs in crash cart trolleys. Thus, this study was conducted to assess the effect of an educational intervention on knowledge of crash cart drugs and equipment management among nurses.

Methods: This is a pre-experimental research design conducted at Shahid Gangalal National Heart Center, Kathmandu, Nepal.A simple random sampling technique was adopted. A semi-structured questionnaire was used to identify the knowledge of nurses. A standard checklist was used to observe crash cart trolleys. Pre and post test data was taken. Outcome variables included knowledge of crash cart trolleys organization and well organized crash cart in diferent wards. Data were analyzed to compare the knowledge before and after the intervention. Chi-square test, pair t-test, and linear regression multivariable model used for statistical analysis.

Results: A total of 134 nurses were recruited in this study. The overall mean score of knowledge was signifcantly higher in post-intervention. The total knowledge mean score difference among nurses was -11.07, (p<0.001), drug content difference at crash cart was -16.85, (p<0.001), equipment content at crash cart was -24.42, (p<0.001).The linear regression showed significant improvement in knowledge at post-intervention (β; 0.928, 95% CI; 10.52, 11.57, p<0.001), when adjusted for age, education, work experience, working unit and CPR training.

Conclusion: Knowledge and organization of crash cart was improved after educational intervention.

Predicting Surgical Mortality After Congenital Heart Surgeries Using Risk Adjustment in Congenital Heart Surgery-1 (RACHS-1) Risk Scoring System: A Retrospective Analysis in A Single Tertiary Center

Smriti Mahaju Bajracharya, Dikshya Joshi, Sidhartha Pradhan — Sun, 05 Nov 2023 00:00:00 +0000

Objective: The main objective of our study was to analyze the in-hospital mortality in children who underwent surgery for congenital heart defects in a single tertiary cardiac center in Nepal using RACHS-1 risk score during 6 year period.

Methods: After approval from Institutional Review Board, retrospective data analysis were performed from June 2013 to June 2019 at Shahid Gangalal National Heart Centre. Patients younger than 14 years, who underwent cardiac surgery for congenital heart defects, were enrolled. Data from patient records regarding the age, gender, weight, diagnosis, procedures performed, cardio‑pulmonary bypass (CPB) time and aortic cross‑clamp (AoX) were obtained. The operations were classifed according to the six RACHS-1 categories and patients were allotted to RACHS-1 categories retrospectively by matching the procedure of each patient with a risk category.

Results: Two thousand four hundred and seventeen patients underwent surgeries for congenital heart diseases who were classifed according to the RACHS‑1 score. Among the patients, 56.1 % were male and 20.1 % were younger than one year of age. The mortality was 1.5%,13.3%, 21.7% and 73.4% for category 1, 2, 3 and 4 respectively. The overall ability of the RACHS‑1 classifcation to predict in‑hospital mortality Area under the ROC curve was 0.736 with 95% confdence interval (CI) of 0.709-0.763.

Conclusion: The RACHS‑1 classification is applicable to our pediatric populations which was a useful and easily applicable tool, requiring only very few data for mortality risk in our hospital although there are other factors that have an impact on the mortality.

Takotsubo Cardiomyopathy in the setting of Urosepsis

Awin Saraf, Anish Hirachan, Ranjit Sharma — Sun, 05 Nov 2023 00:00:00 +0000

Takotsubo cardiomyopathy is a rare cardiac condition associated with transient left ventricular apical wall motion abnormalities in association with stress but without any signifcant coronary artery disease. We present a case of takotsubo cardiomyopathy presenting as acute pulmonary edema in the background of urosepsis.

Spontaneous Epidural Hematoma: A rare neurological complication in a patient following routine coronary angiography

Sun, 05 Nov 2023 00:00:00 +0000

Spinal epidural hematoma is an uncommon but potentially devastating complication associated with various medical interventions. We present a case report of this rare neurological complication following a routine coronary angiography. A 69-year-old male with Aortic Stenosis presented for a scheduled coronary angiography to assess his cardiac status before valve replacement. The procedure was uneventful but approximately 15 minutes after the angiography, he developed sudden-onset of rapidly progressing weakness and numbness in bilateral lower extremities. An urgent neurologic evaluation revealed signs of spinal cord compression, prompting a magnetic resonance imaging (MRI) scan which showed an extensive spinal epidural hematoma spanning multiple levels within the cervicothoracic spine. This case highlights the importance of recognizing this rare but a potential complication following routine coronary angiography even in the absence of signifcant procedural complications. Timely diagnosis and prompt surgical intervention are crucial for achieving favorable outcomes and minimizing morbidity associated with this condition.

Hyper-dominant Left Anterior Descending Artery in the coronary circulation as a rare coronary anomaly

Sun, 05 Nov 2023 00:00:00 +0000

Hyper-dominant left anterior descending artery is rarely seen in the coronary distribution. Its involvement in ACS can often be detrimental as it supplies most of the anterior and inferior part of the right and left ventricles in compared to other variants of LAD artery. It is required to be recognized earlier and management strategies should be ascertained. Our report here describes such a case of anomalous coronary artery which is less commonly encountered during Coronary Angiography. This was case of a 60 year old hypertensive male who presented with atypical chest pain had normal ECG, echocardiography and cardiac biomarkers but TMT was positive, subsequent Coronary angiographic evaluation came up with LAD artery which was going beyond apex in the posterior interventricular groove up to crux forming PDA with 20 to 30% stenosis in proximal to distal part. Such a large LAD running into the interventricular groove forming PDA is known as “Hyper-dominant” LAD artery. The Right Coronary artery was non-dominant. Fortunately, there was no signifcant coronary artery disease to explain the cause of his chest pain, but the artery had unusual distribution provided that it has sole territorial supply to larger part of the myocardium which can worsen the clinical status if coronary artery disease progresses. He was kept under medical management and was doing good. The “Take away” lesson is that there are very few subjects with Hyper-dominant LAD artery till date and most other cases with this anatomy had presented with myocardial infarction and thus such anatomical variant of LAD artery ought to be matter of concern and further research in the feld of cardiology.