Nepalese Heart Journal

How do the cardiology services for patients presenting with acute coronary syndromes compare between developing and developed countries?

Dominic Mears — 2019-04-30

Background and Aims: Acute Coronary Syndromes (ACS) represent a significant challenge for healthcare systems worldwide, however there is a vast disparity between developed and developing countries in terms of their management and subsequent patient outcomes. The aim of this reflective report was to explore the services provided for ACS patients in the developing country Nepal and compare them to the highly developed United Kingdom. This was with a view to summarise the priorities for Nepal going forward in addressing this major public health challenge and improving their ACS patient outcomes.

Methods: This reflective report was constructed following an elective placement at the Shahid Gangalal National Heart Centre in Kathmandu, Nepal. It involved collecting numerous ACS patient case studies from the United Kingdom (UK) and Nepal and reflecting on their clinical experiences using the Gibbs Reflective Cycle.

Reflective Summary: The treatment strategies for ACS are very similar in both countries, however in Nepal it is more difficult to efficiently transport patients into hospital and the population is less aware of the symptoms of ACS, thus contributing to delayed presentations and poorer outcomes. Furthermore, the provision of non-emergency healthcare, collection of patient data and general hospital resources were understandably deficient in comparison to the UK given the difference in financial status.

Discussion: In order to address the rising incidence of ACS, Nepal should prioritise investment in the hospital facilities provided for these patients, including suitably equipped emergency transport and cardiac catheterisation laboratories. In addition, they should work towards an electronic patient database and more established non-emergency healthcare services. Perhaps most importantly is the need for improved health promotion about the risk factors for ACS and the signs of a heart attack.

Health information system as an integral component of cardiovascular surveillance system in Nepal

Sahadeb Prasad Dhungana — 2019-04-30

Introduction: Nepal lacks a comprehensive, integrated health information system (HIS) to address the growing burden of cardiovascular diseases (CVDs).

Method: We performed a literature search and reviewed papers, government reports, and websites related to HIS. We included existing situations of HIS, major gaps, strength weakness opportunity threat (SWOT) analysis and role of different stakeholders to address CVD burden in Nepal.

Results: Health data from different health facility level are filled in district health information software (DHIS-2). DHIS-2 has been implemented in 10 districts in full-fledged manner and partial phase in 22 districts. Data are collected by means of paper-based registers, tally sheets, and monthly data collation forms. The collated data are sent monthly to the district level and entered into the computer using DHIS-2 software and submitted to the national health departments.

Major gaps in health management information system (HMIS) are lack of separate heading of CVDs and lack of implementation of the existing data collection system. The strengths of the HIS are robust and decentralized health care delivery system in a good number of medical institutions. Weakness is lack of public and private partnership, concrete policy on health information and dissemination. Opportunities are the existence of policies and regulations mandating health facilities to report indicators, the involvement of private institutions and the expansion of existing DHIS-2 system.

Conclusion: Nepal currently lacks reliable and accurate data on timely manner to address the growing burden of CVDs. There is a need to strengthen the existing DHIS with a commitment from expertise and leadership.

Recent experience on atrial septal defect device closure at Shahid Gangalal National Heart Centre, Kathmandu, Nepal

Chandra Mani Adhikari — 2019-04-30

Background and Aims: Atrial septal defect (ASD) device closure has been accepted worldwide as an alternative to surgical closure with the excellent results. This interventional, non-surgical technique plays an important role in the treatment of ASD. This audit aims to report our experience of ASD device closure in our centre.

Methods: This cross sectional study was conducted at Shahid Gangalal National Heart Centre, Kathmandu, Nepal. All patients who were attempted for ASD device closure from February 2016 to January 2018 were included. ASD size, device size, procedural approach, and device implantation success rates were retrospectively analyzed from our hospital records.

Result: During the study period, 566 cases were attempted for device closure. Among them device was successfully implanted in 557(98.4% of cases). In nine cases ASD device could not be implanted. Among the 557 successful cases, 401 (71.9%) were female. Age ranged from 5 to 72 years with the mean of 30.9 years. In five patients, transcatheter closure cases, was done under general anesthesia with the guidance of transesophgeal echocardiogram. In all other patients, device closure was done in local anesthesia under transthoracic echocardiography guidance. ASD size ranged from 7mm to 37mm with the mean of 20.8mm. ASD device ranged from 8 to 42mm with the mean of 26.5mm. Four different devices were used with the Amplatzer septal occluder used in 527 (94.6%) patients, hyperion( Comed) device in 10 (1.7%) patients, Memopart (Lepu) device in 19 (3.4%) patients and Cera (Life tech) device in 1(0.1%) patients.

Discussion: ASD device closure is a safe and effective procedure.

Effectiveness of awareness raising interventions on knowledge about Rheumatic Heart Disease and change in care seeking behavior for throat infection in Lalitpur, Nepal

Prakash Raj Regmi — 2019-04-30

Background and Aims: Awareness raising is an important component of primary prevention of RHD. Data are lacking on primary prevention activities for rheumatic heart disease (RHD) prevention in Nepal. The aim of this study is to assess the effectiveness of various awareness raising activities on increasing knowledge about throat infection (TI), acute rheumatic fever (ARF) and RHD and their impact on RHD prevention.

Methods: Fourteen randomly selected government health facilities in Lalitpur were enrolled in this study. A baseline study conducted in early 2015 analyzed the level of knowledge about RHD among care seekers attending health facilities in Lalitpur. An expansive public awareness raising activities on RHD were performed for 2.5 years starting from February 2015. Data were collected using structured interviews, and review of health facility records. Data were analyzed to compare the postintervention status with the baseline status.

Results: The mean knowledge about ARF and RHD increased by over 71% (1.82 to 3.12) and 124% (0.37 to 0.83) respectively in post intervention group. There was significant difference in knowledge about TI, ARF and RHD among baseline and post intervention group (p-value<0.0001). The number of throat infection cases presented at health facilities increased by 30.39% from fiscal year (FY) 2071/72 to FY 2072/073 and by 4.69% in the next FY.

Conclusions: Awareness raising interventions are effective in increasing knowledge about TI, ARF and RHD which further can produce positive impact in the primary prevention of ARF and RHD.

Prevalence and associated risk factor of hypertension among individuals of age 18-59 years in South-eastern Nepal: A cross-sectional study

Prajjwal Pyakurel — 2019-04-30

Background: Hypertension is one of the major risk factors for the rising burden of cardiovascular diseases (CVDs) in developing region. It has also been recognized as one of the major public health problems in the developing countries since the early seventies and the rate is increasing not only in urban areas but in rural areas with low socio-economic condition.

Methods: A cross sectional study was conducted in Jogidaha Village Development Comittee(VDC) and Triyuga Municipality of Udaypur district of South-Eastern Nepal. A total of 430 participants of age 18-59 years were selected. Semi-structured questionnaire (WHO NCD STEPS instrument) was used to collect information on demographic variables and associated risk factors with use of show cards. Clinical and anthropometric measurement were done. Primary outcome was prevalence of hypertension. Bivariate and multivariate analysis were performed to show strength of association among various risk factors with hypertension.

Results: The prevalence of hypertension was found to be 25.1%. Prevalence of overweight and obesity was found to be 49.8%. Hypertension was significantly associated with age (AOR=1.09, CI=1.05-1.10) and gender (male >female; AOR= 2.12,CI =1.22-3.68). Similarly, increased waist-hip ratio(7.12; CI 2.87-17.67),alcohol consumption(OR=2.82,CI=1.77-4.52), and use of tobacco products (OR =1.8,CI=1.02-3.20) showed significant association with hypertension.

Conclusion: There is high prevalence of hypertension in rural districts of South-Eastern Nepal. A community-based preventive approach with early detection and treatment and life-style modification is needed to reduce the burden of disease and make sustainable changes.

Clinical characteristics, risk factors and angiographic profile of acute coronary syndrome patients in a tertiary care center of Nepal.

Abhishesh Shakya — 2019-04-30

Background and Aims: Acute coronary syndrome (ACS) refers to a group of clinical symptoms consistent with new onset or worsening ischemic symptoms. ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI) and unstable angina (UA) are the three types of ACS. The objectives were to study the risk factors prevalence, angiographic distribution and severity of coronary artery stenosis in ACS among patients admitted in Cardiology Department of Manmohan Cardiothoracic Vascular and Transplant Center (MCVTC).

Methods: This is a restrospective study of 419 ACS patients admitted and treated in MCVTC from November 2017 to October 2018. Patients were divided into STEMI, NSTEMI and UA then analyzed for various risk factors, angiographic patterns and severity of coronary artery disease.

Results: Mean age of presentation was 59.3Å}12.8 years. Majority were male 317(75.7%). Most patients had STEMI 252 (60.1%) followed by NSTEMI 98 (23.4%) and UA 69 (16.5 %). Risk factors: smoking was present in 241 (57.5%), hypertension in 212 (50.6%), diabetes in 144 (34.4%), dyslipidemia in 58 (13.8%). Single-vessel disease was present in 34.6 % patients, double- vessel disease was present in 27.44 % patients and triple vessel disease was present in 26.3 % patients, left main disease in 1.4 % patients. Normal coronaries were present in 6.4% patients and minor coronary artery disease in 3.8 % patients.

Conclusions: STEMI was the most common presentation. Three quarters of ACS were male patients. Smoking was most prevalent risk factor. Single vessel involvement was the most common CAG finding in all spectrum of ACS. Diabetic patients had more multivessel disease.

Measurement of Hepatocyte Growth Factor, Interleukin 6 and Tumor necrosis factor α in Acute Myocardial Infarction

Asadallah Keshmiri — 2019-04-30

Background: Early mortality rate due to acute myocardial infarction (AMI) is approximately 30%, and half of these deaths occur before reaching a hospital. The prevention and early detection play a key role in reducing mortality in AMI. Hepatocyte Growth Factor (HGF), Interleukin 6 (IL-6), and Tumor Necrosis Factor α (TNF-α) are most recent prognostic biomarkers for AMI. The present study was aimed to evaluate the level of these cytokines in AMI.

Methods: In this case control study, 39 patients with AMI were compared with 30 healthy subjects. Age, sex and other possible confounding factors were matched. AMI diagnosis was confirmed by typical symptoms, electrocardiogram changes and serum concentration of troponin I and creatine kinase-MB. The levels of TNF-α, IL-6 an HGF at baseline and 3 and 7 days later were measured using ELISA method.

Results: Levels of IL-6, TNF-α and HGF increased over time after AMI with ST-segment elevation in study group. The baseline IL-6 levels in AMI group were significantly higher than control group (P<0.05).

Conclusions: The results of this study suggest that baseline levels of IL-6 as well as serial changes of serum IL-6, TNF-α and HGF concentrations can be used as potential diagnostic biomarkers in AMI.

Non alcoholic fatty liver disease is a predictor of subclinical Carotid Atherosclerosis in the presence of Metabolic Syndrome

Cemal Kemaloglu — 2019-04-30

Objective: The aim of this study is to identify the relationship between carotid intima-media thickness (c-imt) and non-alcoholic fatty liver disease (NAFLD), and to determine whether NAFLD is an independent predictor for the progression of atherosclerosis.

Method: This is a prospective randomized controlled study. 103 NAFLD patients who have hepatosteatosis with grade II and above were enrolled in this study. Patients were divided into NAFLD with metabolic syndrome (MS) and NAFLD without MS groups and compared with 50 healthy people. Basal demographic characteristics and C-imt of all patients and control group were measured.

Results: C-imt and carotid cross sectional area rates in the NAFLD groups were significantly higher than those in the control group. The mean and max. c-imt levels were significantly higher in the NAFLD group with metabolic syndrome (p<0,001). Homeostatic Model of Assessment-Insulin Resistance (HOMA-IR) levels were increased in the group with metabolic syndrome than those in the group without metabolic syndrome, with statistical significance (p<0.001). There was no difference in c-imt levels between HOMA-IR positive and negative groups (p=0.254) in patients with NAFLD and without metabolic syndrome. There was only a mild positive corelation between c-imt levels and high sensitive C-Reactive protein (hs-CRP) levels in metabolic syndrome positive group (p=0.026 r=0.30).

Conclusion: NAFLD was a significant predictor to determine the increased risk of carotid atherosclerosis.

Awareness regarding cardiac rehabilitation among patients with coronary heart disease attending a cardiac care centre, Kathmandu valley

Rosy Shrestha — 2019-04-30

Introduction: Coronary heart disease (CHD) is gradually emerging as a leading cause of morbidity and mortality of many low middle income countries like Nepal. Cardiac rehabilitation awareness program has been proved to be effective for reducing the mortality as well as improving the quality of life among CHD patients. The aim of this study was to explore the awareness on cardiac rehabilitation (CR) in patients with CHD attending a cardiac care centre, Nepal.

Method: A descriptive cross sectional study design was used to examine 100 CHD patients attending out-patient departments of Shahid Gangalal National Heart Centre (SGNHC), Kathmandu, Nepal. Purposive sampling technique was used for data collection by face to face interview technique with self developed tool. Data was analyzed with descriptive and inferential statistics.

Results: Of all 100 respondents, 55.0% were male and the mean age was 53.23±14.22 years. The median score of awareness was 17 with interquartile range (IQR) 14.0-19.75 and majority (57.0%) of respondents were unaware about CR. The awareness regarding CR was found highest in awareness regarding CHD (75.0%) whereas lowest score was found in time and duration needed for exercise per week (14.0%). The significant influencing variables were age, education status, duration of treatment and participation in CR program for CHD patients.

Conclusion: The awareness on CR program in CHD patients in Nepal is not optimal, especially among 54 and above age group, illiterate people, those receiving treatment equal & more than 1 year duration and the CHD patients who didn’t get chance to participate on awareness programs. Hence, it is strongly recommended that health professionals including nurses should organize and promote CR programs including counseling session to improve the awareness level and ultimately enhance quality of life of CHD patients.

Transcatheter device closure of atrial septal defect in dextrocardia with situs inversus totalis

Kiran Prasad Acharya — 2019-04-30

Only few cases of Device closure of atrial septal defect in dextrocardia with situs inversus totalis has been reported previously. We present a case of a 36 years old male, who had secundum type of atrial septal defect in dextrocardia with situs inversus totalis. ASD device closure was successfully done. However, we encountered few technical difficulties in this case which are discussed in this case review.

Solitary coronary artery: An unusual cause of atypical chest pain

Laxman Dubey — 2019-04-30

Coronary arteries arising from single coronary sinus is a rare congenital anomaly. We report a 30-year-old male who presented with atypical chest pain and computed tomography coronary angiography revealed a solitary coronary artery originating from a single ostium in the right sinus of Valsalva.

Stroke in young secondary to infective endocarditis complicating hypertrophic cardiomyopathy – A case report

Abhishek Bhandari — 2019-04-30

Hypertrophic cardiomyopathy is an autosomal dominant disease of cardiac sarcomere with the varied clinical presentation. The common manifestations are heart failure (dyspnea), palpitations, chest pain, stroke and even sudden death. Majority of patients are not recognized because of being asymptomatic. Stroke is one of the complications of hypertrophic cardiomyopathy and usually occurs in the setting of atrial fibrillation, advanced age and congestive cardiac failure. Although infective endocarditis is known, but relatively uncommon, complication of hypertrophic cardiomyopathy, it is not reported from Nepal. We report here a case of 42-year male patient with hypertrophic cardiomyopathy in normal sinus rhythm with infective endocarditis who developed malignant cardioembolic stroke involving left middle cerebral artery territory.