Nepalese Heart Journal

COVID-19: Cardiovascular perspective

Kiran Prasad Acharya — 2020-05-06

Introduction: Recently the outbreak of COVID-19 has created a nuisance in the health care system throughout the world. There are multiple early reports covering the cardiovascular perspective of COVID-19. However, there are limited guidelines/protocols addressing the issue. With the emerging pandemic, data is ever-changing and so is our understanding of the cardiovascular implication of COVID-19.

Shahid Gangalal National Heart Centre-ST-elevation Myocardial infarction Registry (SGNHC-STEMI-Registry), Nepal

Chandra Mani Adhikari — 2020-05-06

Background and Aims: Incidence of ST-elevation myocardial infarction (STEMI) is increasing in Nepal. We aim to describe the presentation, management, complications, and outcomes of patients admitted with a diagnosis of STEMI in Shahid Gangalal National Heart Centre (SGNHC), Nepal.

Methods: Shahid Gangalal National Heart Centre-ST-elevation registry (SGNHC-STEMI) registry was a cross sectional, observational, registry. All the patients who were admitted with the diagnosis of STEMI from January 2018 to December 2018 were included.

Results: In this registry, 1460 patients out of 1486 patients who attended emergency were included. The mean age of patients was 60.8±13.4 years (range: 20 years to 98 years) with 70.3% male patients. Most of the patients (83.2%) were referred from other hospitals and 16.8% of patients directly attended the SGNHC emergency. During the presentation, smoking (54%) was the most common risk factor, followed by hypertension (36.6%), diabetes mellitus (25.3%), and dyslipidemia (7.8%). After admission, new cases of dyslipidemia, HTN, Impaired Fasting Glucose (IFG), and Type 2 DM were diagnosed in 682 (51.3%), 182 (20.1%), 148 (10.3%) and 95 (8.9%) respectively. At the time of presentation, 73.3% were in Killip class I and 26.3% were above Killip class II with 5.1% in cardiogenic shock. Thirty-one percent of the cases received reperfusion therapy (Primary percutaneous intervention in 25.2% and fibrinolysis in 5.8%). Inferior wall MI was the most common type of STEMI. Among the patients who underwent invasive therapy, the multi-vessel disease was noted in 46.2% cases and left main coronary artery involvement in 0.7% cases. In-hospital mortality was 6.2% with cardiogenic shock being the most common cause. Aspirin (97.8%), clopidogrel (96.2%), statin (96.4%), ACEI/ARB (76.8%) and beta-blocker (76.8%) were prescribed during discharge.

Conclusion: The SGNHC-STEMI registry provides valuable information on the overall aspect of STEMI in Nepal. In general, the SGNHC-STEMI registry findings are consistent with other international data.

Precipitating factors leading to decompensation of heart failure in patients attending a tertiary care centre of Nepal

Suman Adhikari — 2020-05-06

Background and Aims: Heart failure is one of the debilitating conditions in patients with various forms of heart disease. It can have impacts on various aspects of the life of a patient. There have been few studies on the etiological aspects and precipitants of heart failure in the Nepalese population. The aim of our study is to find out the major factors that lead to decompensation of heart failure in patients who already have established heart failure.

Methods: This study was a single-centre, prospective, observational study conducted in the emergency department of Manmohan Cardiothoracic Vascular and Transplant Centre (MCVTC) from 1st June 2019 to 30th November 2019. Hundred and one patients with established heart failure in the past, who presented again with decompensated heart failure were enrolled.

Results: The mean age of the patients was 62.81 years (SD=15.92). Factors responsible for acute decompensation of heart failure were identified in 95.0 % of patients included in the study. The most common factor identified was poor compliance with medications and diet and fluid intake (38.6%). Next to it was arrhythmia identified in about 35.6% of cases.Other important factors responsible for decompensation in our study were infection (12.8%), anemia (4.9%) and ischemia (2.9%).

Conclusion: Preventable and identifiable factors are responsible for the decompensation of heart failure. Most of these factors can be modified with the use of proper patient counseling/patient education, thereby reducing recurrent hospital admissions and economic burden to the patient and the government as well.

Comparative study between the use of St. Thomas' II cardioplegia and del Nido cardioplegia in patients who underwent open-heart surgery

Satish Vaidya — 2020-05-06

Background and Aims: Cardioplegia is used to arrest the heart after the application of an aortic cross-clamp that interrupts the coronary circulation. Commonly used St. Thomas’II cardioplegic solution has to be repeated at short intervals, which may cause additional myocardial injury. So, this study is done to determine whether del Nido (DN) cardioplegia, which has a longer duration of arrest with a single dose, provides equivalent or better myocardial protection as compared to St. Thomas’ II Cardioplegia.

Methods: A prospective observational study was done among 100 patients who underwent open-heart surgery with myocardial protection, between September 2016 to August 2018 in Bangabandhu Sheikh Mujib Medical University, Bangladesh. Patients were divided into two groups, group A (n=50) for del Nido cardioplegic and group B (n=50) for St. Thomas’ II cardioplegia. We compared the amount of cardioplegic solution, Aortic cross-clamp time, cardiopulmonary bypass (CPB) time, ischemic time, arrhythmia, spontaneous sinus rhythm after declamping, intraoperative DC shock requirement, postoperative left ventricular ejection fraction, serum potassium level, low cardiac output, cardiac Troponin level I and CK-MB release after 12 hours and 24 hours, presence of myocardial infarction and death.

Results: The per-operative variable suggested spontaneous activity during a cardiac arrest was 2% in del Nido and 14% in St. Thomas’ II group (p=0.044). Similarly, during intraoperative phase spontaneous restoration of cardiac activity after the procedure in del Nido was 2.90 ± 1.16 minutes and in St. Thomas’ II was 1.8 ± 0.615 minutes (p=0.001). However total bypass time and ischemic time were not significant. During the postoperative period, Troponin I and CKMB were measured at 12 hours and 24 hours which were not statistically different in two groups. Postoperatively, low output syndrome was seen among 3 patients in del Nido Group and 4 patients in St. Thomas’ II group (p-value=0.341).

Conclusion: This study showed with the use of del Nido cardioplegia provides equivalent myocardial protection to St. Thomas’ II cardioplegia, with the use of only single-dose cardioplegia.

Adherence to guideline-directed medical therapy among left ventricular systolic dysfunction patients in Shahid Gangalal National Heart Centre, Kathmandu, Nepal

Reeju Manandhar — 2020-05-06

Background and Aims: Heart Failure (HF) with reduced Ejection Fraction (HFrEF) is defined as the clinical diagnosis of HF and left ventricular ejection fraction (LVEF) ≤ 40%, also referred to as systolic HF. Guideline-directed medical therapy (GDMT) has shown to reduce mortality for HFrEF. We aim to evaluate adherence to GDMT treatment in our outpatients.

Methods: It was a cross-sectional observational study. All patients who attended the Department of preventive medicine and cardiac rehabilitation for medical counseling from October 2016 to May 2018 and have already completed 3 months of follow up for HF were included in this study. Performa was designed to collect patient information which included; age, gender, NYHA functional class, LVEF, systolic and diastolic blood pressure, pulse rate, creatinine, potassium and drugs with doses were recorded.

Results: Among the 451 patients, ninety-nine (65.6%) were male and 52 (34.4%) were female. The mean age was 56.2±4.2 years. Most of the patients were in NYHA class II 114 (75.5%) and in Sinus rhythm 119 (79.4%). Mean LVEF was 26.6±6.1%. Dilated Cardiomyopathy was the most common clinical diagnosis in 76 (50.3%). Diuretic, Angiotensin-converting enzyme inhibitor (ACEI)/Angitensin receptor blocker (AB), Aldosterone Antagonist, β-blocker and digoxin were prescribed in 151 (100%), 140 (93.3%), 127 (84.1%), 114 (75.4%) and 46 (30.4%) patients respectively. The mean dose of furosemide, Enalapril, Losartan, carvedilol, bisoprolol and metoprolol succinate was 45.3mg, 4.0mg, 33.2mg, 33.6mg, 18.8mg, 3.0mg, and 27.5mg was respectively.

Conclusion: Our center's adherence to GDMT in HFrEF patients is comparable to international studies. We still need more effort to re-emphasize the importance of GDMT by focusing on the optimization of drug doses during out-patient visits.

Knowledge, Attitude and Practices regarding Cardiovascular Diseases among people of Pakhribas municipalty of Eastern Nepal

Manisha Shrestha — 2020-05-06

Background and Aims: Cardiovascular diseases (CVDs) are the leading cause of death globally with 17.9 million deaths in 2016. Nepal is facing a high burden of non-communicable diseases (NCDs) with 66% of people dying from NCDs in 2018. In this study, we aim to assess the knowledge, attitudeand practice regarding CVDs among people of Pakhribas Municipality in Eastern Nepal.

Methods: Observational cross-sectional study was conducted among residents of Pakhribas Municipality in eastern Nepal from 9th December to 22nd December 2018. We recruited a convenient sample of 458 permanent residents of Pakhribas municipality. A semi-structured questionnaire based on the CARRF-KL scale survey for knowledge, attitude and practice (after thorough literature review) was used to elicit the information. Descriptive and thematic analysis was done.

Result: Fifty-five percent of the respondents belonged to the age group of 30-60 years. Half of the respondents were females. Janjati community was the most dominant ethnicity. One-fourth of the participants were illiterate. The knowledge was found to be average with only 51.5% realizing that family history of CVDs increases the risk of CVDs. Similarly, 46% didn’t know that coronary heart disease could be prevented. The attitude was found to be good with 90.4%, 93.6% and 90.6% respectively stating that they will exercise more, change eating habits and quit smoking if they had CVDs. Regarding practices, people visit traditional healers when they are ill and drink alcohol to fight cold despite knowing it as a risk factor for CVDs.

Conclusion: The knowledge of people of Pakhribas Municipality regarding CVD was average. However, the attitude was good. Regarding the practice, people have mixed practices.

Atrial stenting: case based elaboration of indications

Neeraj Awasthy — 2020-05-06

In certain forms of congenital and acquired heart defects, wide interatrial communication is important to maintain hemodynamics. In comparison to balloon septostomy or blade septostomy, atrial septal stenting provides a controlled, predictable, and longlasting atrial communication particularly in children and older age groups. Even though there are theoretical high risks of embolization, atrial stenting proves to be an effective palliative method. We describe 3 cases that underwent atrial stenting for different hemodynamic reasons. All three cases had different age groups. Two of them were moribund sick. Cases were performed under general anaesthesia with the help of transthoracic and transesophageal echo. Since it is uncommon procedure, we hope that this paper will the help in understanding clinical applications.

Peripartum Cardiomyopathy and Systemic Lupus Erythematosus Carditis, a diagnostic dilemma

Binod Poudel — 2020-05-06

A young woman at 8 months postpartum presented with dyspnoea, orthopnoea and swelling of lower limbs in which physical examination, chest radiography and echocardiogram were suggestive of acute congestive heart failure with left ventricle dilatation and dysfunction. A suspicion of peripartum cardiomyopathy was made and treated with conventional drug therapy but the patient continued to develop multiple episodes of heart failure. Over time she developed fever and polyarthritis following which autoantibodies, complement level and 24-hour urinary protein were done which helped us to make the diagnosis of Systemic Lupus Erythematosus (SLE) nephritis. The patient was started on high dose corticosteroids. However, after a week, patient developed cardiogenic shock following which intravenous pulse Cyclophosphamide was started and the patient improved clinically and biochemically.

Successful repair of Aortic Rupture in a patient with bicuspid aortic valve after Aortic Valve Replacement: a rare case

Dikshya Joshi — 2020-05-06

The occurrence of acute aortic rupture after aortic valve replacement is unusual; but catastrophic. We report a case of a 71-year-old gentleman with a bicuspid aortic valve who developed acute aortic rupture after an elective bioprosthetic aortic valve replacement surgery in which successful repair was carried out with the preservation of the prosthetic valve.