CONQUERING HEART DISEASE IN THE HIMALAYAN REGION

Transcription

1 CONQUERING HEART DISEASE IN THE HIMALAYAN REGION International Conference November 2010 Venue: Hotel Hyatt Regency, Kathmandu, Nepal

2 Nepalese Heart Journal (NHJ) An official publication of Cardiac Society of Nepal NHJ VOLUME 7 NO. 1 NOVEMBER, 2010 Editorial Board Chief Editor Dr. Deewakar Sharma Editors Dr. Sujeeb Rajbhandari Dr. Rajendra Koju Dr. Sajan Gopal Baidya Dr. Ram Kishor Shah Cardiac Society of Nepal Executive Committee ( ) Patron Dr. M. R. Pandey President Dr. Abani B. Upadhyaya Immediate Past President Dr. Arun Sayami Vice President Dr. Bhagawan Koirala General Secretary Dr. Yadav Kumar Deo Bhatt Joint Secretary Dr. Rajendra Koju Treasurer Dr. Jeju N. Pokharel Joint-Treasurer Dr. Rabindra Timila Member Dr. R.K. Shah Dr. Rajib Rajbhandari Dr. Shankar Adhikari Dr. Sajan Gopal Baidya Dr. Ranjit Sharma Contact: Cardiac Society of Nepal Shahid Gangalal National Heart Centre Bansbari, Kathmandu, Nepal Phone: , Fax: csofnepal@hotmail.com, csofnepal@gmail.com Design By: Santosh Dhakal Mob: Phone: wannabesuccess@gmail.com Shahid Gangalal National Heart Centre

3 CONQUERING HEART DISEASES IN THE HIMALAYAN REGION INTERNATIONAL CONFERENCE ORGANIZING COMMITEE Patron (Cardiac Society of Nepal) M.R. Pandey President Abani B. Upadhyaya General Secretary Yadav Bhatta Scientific Committee Chairman Bhagawan Koirala Members Arun Maskey Jyotindra Sharma Man Bdr. K.C. Prakash Raj Regmi R K Shah Ratna Raj Poudyal Sanjib Dhungel Udaya K. Shrestha Yadav Bhatta Finance Committee Chairman Jeju Nath Pokharel Members Damodar Pokharel Gopi Hirachan Khaled Hussain Narayan Gautam Rabi Malla Rajib Rajbhandari Ranjit Sharma Shankar Adhikari Sujeeb Rajbhandari Sunil Jha T.N. Bhattarai Yadav Bhatta Publication Committee Chairman Deewakar Sharma Members Bikash Dali Moti Raja Bajracharya Rajendra Koju Sujeeb Rajbhandari Sajan G. Baidya Hospitality Committee Chairman Sajan G. Baidya Members Denis Shrestha Devendra Khatri Harihar Khanal Lava N. Joshi Rabindra Timala Ramesh Koirala Ranjit Sharma Advisory Committee D.B. Karki Lok B. Thapa Govinda Sharma Arun Sayami

4 CONQUERING HEART DISEASES IN THE HIMALAYAN REGION INTERNATIONAL CONFERENCE INTERNATIONAL FACULTY NATIONAL FACULTY Abdul Malik (Bangladesh) Anil Dhall (India) Ashok Seth (India) Du Zhi Min (China) Gaury Adhikari (USA) H.S Rissam (India) JinShu (China) Liu Tongku (China) Milan Chag (India) Mohan Nair (India) Nishit Chandra (India) Praveer Agarwal (India) R. K. Khandaker (Bangladesh) Rajeev Gupta (India) Rajesh Sharma (India) Rajneesh Malhotra (India) Ravul Jindal (India) S. RadhaKrishnan (India) Shirish Hiremath (India) Subash Chandra (India) Tom Peter (USA) V K Bahl (India) W.S Santharaj (SriLanka) Wu Guifu (China) A B Upadhyaya A Maskey A Sayami B Koirala B Rawat D B Karki D Khatri D Pokhrel D Sharma D Shrestha H Khanal J Pokarel J Sharma K Acharya K Hussain LN Joshi M R Pandey MR Bajracharya MB KC N Adhikari N Gautam R K Shah R Koirala R R Poudel R Koju R Malla R Rajbhandari R Raut R Sharma R Timala S Adhikari SG Baidhya S Jha S Rajbhandari S Regmi S Dhungel U Shakya U Shrestha V K Bahl Y Bhatt

5 NHJ VOLUME 7 NO. 1 NOVEMBER, 2010 (special issue)

6 Message Dear Colleagues and Friends, We remember that the first scientific medical journal of Nepal Journal of Nepal Medical Association being published in the year The First issue of Nepal Heart journal was published almost a decade ago. We are delighted to present the seventh edition of the Journal at the occasion of the International Conference. Over the last four or five decades, we have witnessed the rapidly increasing burden of C.V.D. in our country and region. The most distressing fact is that the disease is now affecting younger people and also people from lower socio economic status. This fact has been well recognized by W.H.O. and now even by the United Nations. Awareness building and preventive actions are being taken but this has got to be substantially accentreated., if we are to control the emerging epidemic. The Inter Heart study, in which Nepal also made significant contribution has show that 90% of Myocardial Infarction is caused by nine controllable risk factors. So, the knowledge is there, but more action is needed. Chronic diseases like most heart diseases requires life long treatment and it is very difficult for patients from lower socio economic status to afford the same. Social health insurance is the ideal but in the meantime, the treatment and medicine can be made cheaper by means like producing less costly on primary quality generic drugs and we should focus more on primary care for prevention, control and treatment. We like to take this opportunity to welcome all the International Delegates and to learn from their visit experience. We hope they will enjoy their stay in our country. Lastly, I would like too thank you the Editor-in-chief Dr. Deewakar Sharma and his team for presenting such a nice edition of the Journal. Dr. M. R. Pandey Patron, Cardiac Society of Nepal

7 Message Dear Friends Ladies and Gentlemen, I am delighted that Cardiac Society of Nepal is presenting this edition...of Nepal Heart Journal to our colleagues. Our journal will naturally reflect first and foremost the interest of members of the Cardiac Society which is predominantly, though not exclusively centered in the clinical aspect ot heart disease. At the same time Nepal Heart Journal and Cardiac Society will work to serve all those interested in teh field of heart and circulation. The WHO reports show that heart disease and stroke kills some 17.5 million people a year worldwide. This is almost one third of all annual deaths. We know that the prevalence of heart disease is increasing in our region day by day. The speculation from WHO that by 2020, heart disease and stroke will be the leading cause of both death and disability globally with the number of fatalities projected to intense to over 20 million a year, is alarming. By the year 2030 this figure may rise to over 24 million. The burden of cardiovascular disease is not only increasing but also shifting from developed to developing countries, from elderly to yound, from man to women, from town to village, from rich to poor. The WHO notes: the old stereotype of cardiovascular diseases affecting only stressed, over weight middle aged men in developed countries no longer applies today. Men, women and children are at risk as 80% of the burden is in low and middle income countries. Heart disease and stroke not only takes lives but also causes enormous economic burden. I hope Nepal Heart Journal will give some academic insight to all our friends and supporters and update knowledge in a way that would be beneficial in our service to humanity. I am sure this journal will render invaluable service to cardiology and maintain a standard and reputation at par with leading scienticie journals of the world. On behalf of Cardiac Society of Nepal, we are greatly honored and pleased to welcome all the delegates to our International Conference 2010: Conquering Heart Disease in the Himalayan Region. I also take this opportunity to welcome all the international delegates to this beautiful country Nepal. My special thanks to editor-in-chief Dr. Deewakar Sharma and his team for their contribution to this journal. Wish you all the best. I work with heart. Abani Bhushan Upadhyaya President Cardiac Society of Nepal

8 Message In the last few decades development of science has modified the scenario of diseases to such an extent that now a days the course of many infective and non infective diseases has changed significantly. Many of these diseases have been eradicated or become rare and many have been made ease to diagnose and treat. This has significantly decreased the morbidity and mortality of the general population. The scenario of cardiovascular disease is similar. Many of the infective cardiovascular diseases (CVD), like Rheumatic Heart Disease, are becoming rarer while non infective CVDs like coronary artery, Cardiomyopathies, arrhythmias and alike still pose a challenge to the modern science. As heart is a very vital organ in the body which acts like the hard disk of a modern computer, any problem with it is directly linked to mortality or at least a major morbidity. Cardiology is the field in medicine where there has been maximum number of researches. This has led to tremendous development in the prevention and treatment of CVDs. Despite this, CVD remains to be one of the major killers in the world. We as science practitioners should realize that science is there to be falsified; in fact science is waiting to be falsified. Hence it is obvious that the medicine we are practicing today is meant to be obsolete tomorrow, and to keep up with the pace of medical development and prevent self medical decay, it is mandatory for the present medical practitioner to update themselves. I feel activities like seminars, conferences and workshops are not only effective modalities to update and exchange ones knowledge but also an opportunity to rectify ones mistakes and misconceptions. Concurring Heart Diseases in the Himalayan Region is the first international conference in Cardiology in Nepal and I hope all our colleagues extract maximum benefit from it. I would like to thank the national and international faculty for being kind enough to participate and encourage our endeavor to update cardiovascular practice in Nepal. Thank you. Dr. Yadav Kumar Deo Bhatta Secretary, Organizing Committee General Secretary Cardiac Society Of Nepal

9 Message This is my pleasure to write this message for Nepal Heart Journal, on the occasion of International Conference on Cardiovascular diseases. I believe this conference will bring together a lot of experts from the region and outside, and provide a platform for sharing of new knowledge, skills and technology. This will positively impact on the way we shall treat our patients. I would like to thank all guest speakers, moderators and the authors of paper for their significant contributions towards making this conference a success. Bhagawan Koirala Chairman Scientific Committee

10 Editoral First of all, I would like to welcome all the delegates of the international conference. This is a special issue of NHJ published on the occasion of international conference, Conquering Heart disease in the Himalayan region. We have included our regular articles and features as well as abstract of the papers presented in the conference in this issue. We hope this conference will further help in upgrading our knowledge and improve our services in the country. We also hope this will improve interaction among our colleagues and experts from abroad. Nepal is a developing country with limited resources. Though there have been some great achievements in health sectors in some areas like reducing infant and maternal mortality. Our healthcare system needs to undergo lots of improvement and change to serve majority of the people. Moreover, political instability is major factor that prevents us from implementing good policy and plans. Despite all odds, the field of cardiology has grown tremendously in the last 15 years in Nepal. Now all most all advanced cardiology and cardiac surgery services are available inside the country. But, these facilities are only available in urban areas. Majority of the people who live in rural areas even lack basic health care facilities. This may be also more or less true for other developing countries. Prevalence of rheumatic heart disease has not decreased significantly in many developing countries including ours. On the other hand, Hypertension, Diabetes, tobacco use, obesity have significantly increased leading to alarmingly increased prevalence of coronary artery disease, stroke and chronic kidney disease. So, It is unfortunate that developing countries are fighting with both communicable and non communicable diseases in large scales at the same time. The cost involved in treatment of non-communicable diseases whether it is drug or devices or surgery is very high and beyond the reach of majority of the population. Government of Nepal has come up with schemes like child assistance program, free heart valve program, senior citizen program under which many people have benefitted. This kind of revolutionary steps taken by government with such limited resources has great impact in the society but still it is not adequate. The most effective answer to this is to plan and invest in prevention of cardiovascular diseases, which is a hot topic worldwide now.

11 Formal cardiology and cardiac surgery training programs have been already started in the country, which is another landmark in the development of cardiac services. Before this, we had to go abroad for specialized training. We also need to work on improving our research capabilities. Organizing this type of international conference is also an effort of cardiac society of Nepal to promote research and interaction with international community and from now onwards, we plan to organize this type of conference on regular basis. I would like to thank all international and national faculties for accepting our invitation and coming all the way to attend the conference. I would also like to thank all the delegates, colleagues, sponsors, event managers for making this conference happen. I am very grateful to editorial team and publication committee for their contribution in publishing the journal. Dr Deewakar Sharma Chief Editor / Chairman, Publication Committee Nepalese Heart Journal

12 Nepalese Heart Journal (NHJ) An official publication of Cardiac Society of Nepal NHJ VOLUME 7 NO. 1 NOVEMBER, 2010 TABLE OF CONTENTS PART I ORIGINAL ARTICLES 1-52 Review of Ischemic Heart Disease Patients admitted in Dhulikhel Hospital 1-4 Gurung RB, Pant P, Pokharel B, Koju R, Bedi TRS Diagnostic Cardiac Catheterization for Congenital Heart Disease in Nepal 5-7 Regmi SR, Maskey A, Dubey L, Malla R, Bhatt Y, Rajbhandari R, Limbu YR, KC MB Effect of Oral Clonidine on Hemodynamic Response During Surgery 8-14 Regmi BS, Regmi SR, Pradhan B, Marahatta MN, Dubey L Socio-economic Analysis and the Study of Prevalence, Awareness, Treatment, Controll and Risk Factors of Hypertension in Hospital Staff Shakya S, Bhattarai J, Rawal K, Kunwar AR, Shakya YR, Sharma D A study on major cardiovascular risk factors in Acute Coronary Syndrome (ACS) patient 40 years and below admitted in CCU of Shahid Gangalal National Heart Centre Adhikari CM, Rajbhandari R, Limbu YR, Malla R, Sharma R, Rauniyar B, Rajbhandari S, Baidya S, Sharma D, Maskey A, KC MB Observational Study of Pulmonary Embolism Patients in Shahid Gangalal National Heart Centre Rauniyar B, Adhikari CM, Rajbhandari R, Limbu YR, Malla R, Sharma R, Rajbhandari S, Sharma D, Maskey A, Singh SK, Prajapati D, Joshi D, KC MB Tricuspid Valve Infective Endocarditis In Drug Abusers: Clinical Features and Results of Surgical Treatment Medvedev AP, Lashmanov DI, Bhandari Krishna, Chiginev VA, Pichugin VV, Zemskova EN Prevalence of Hypertension in Semi-Urban area of Nepal Koju R, Manandhar K, Gurung R, Pant P, Bedi TRS Study of Cerebrovascular Disease at Dhulikhel Hospital Pokharel BR, Pant P, Gurung R, Koju R, Bedi TRS, Pathak M Initial Experience of Transesophageal Echocardiography in NAMS Bir Hospital Shah RK SHORT COMMUNICATION How to improve drug compliance in hypertensive patients Dr Abdul Rasheed Khan How I do it Aortic Valve Replacement in case of Double Valve Replacement Dr Rabindra B. Timala PART II 53 ABSTRACTS 54-78

13 PART I ORIGINAL ARTICLES / REVIEWS

14 ORIGINAL ARTICLE Review of Ischemic Heart Disease Patients admitted in Dhulikhel Hospital Gurung Ram Bahadur, 1 Pant Pankaj, 2 Pokharel Baburam, 3 Koju Rajendra, 4 Bedi TRS. 5 * Dhulikhel Hospital, Kathmandu University Hospital ABSTRACT The ischaemic heart disease is one of the most common cause of preventable deaths. The number of deaths due to ischaemic heart disease has been reported to be on the rise in the low and middle income countries. Data on the prevalence and risk profile of ischaemic heart disease is scarce in Nepal. The aim of this study was to analyze the demographic and risk profile of patients with ischaemic heart disease admitted at Dhulikhel hospital. 115 patients in the period between 2008 to 2009 with the diagnosis of ischaemic heart disease were identified and analyzed. The mean age of patients with IHD was 62.9+/ years and the youngest was aged 34 years. The number of male patients was greater (54.8%) than the females (45.2%). Among the risk factors hypertension and diabetes were more common in females, whereas smoking was more common in males. The study also showed more people with IHD came from rural than urban areas. In conclusion, the ischaemic heart disease is a rising public health problem affecting even the younger age groups and people from lower socioeconomic strata. Key words: Ischaemic heart disease, Coronary Risk Factors, Dhulikhel hospital. Correspondence: Dr. Ram Bahadur Gurung MD Department of Internal Medicine Dhulikhel Hospital, Kathmandu University Hospital GPO 11008, Kathmandu Nepal. address: ramgurung@hotmail.com Mobile: Hospital Phone: (Ext: 215) 1

15 INTRODUCTION Ischaemic heart disease is one of the most common cause of preventable death and ranks fifth in terms of disease burden. 1 Whereas age-adjusted cardiovascular death rates have declined in several developed countries in past decades, rates of cardiovascular diseases have risen greatly in low-income and middle-income countries. 2 In 1990, two-thirds of the 14 million cardiovascular fatalities occurred in the developing countries. 3,4,5 Although, there has been emerging data on the prevalence of ischaemic heart disease in developing countries like India and other Asian regions, the national level data from Nepal is lacking. However, there are few hospital-based studies which have attempted to estimate the prevalence rate and analyze the associated risk factors for IHD. One study from Dharan showed the prevalence rate of 5.7% in eastern Nepal. 6 Dhulikhel hospital is a university hospital providing its health services largely to the rural community people and some suburban populations. There has been an increasing trend in the rate of admission of IHD patients in recent years in Dhulikhel hospital, probably reflecting the increasing prevalence of IHD in this region of world as well. The aim of this study was to analyze the demographic and risk profile of patients with ischaemic heart disease at Dhulikhel hospital. METHODOLOGY This is a retrospective analysis of 115 cases of ischemic heart disease patients admitted in Dhulikhel Hospital during 2008 and All the patients admitted during this period of time with the diagnosis of acute MI, unstable angina, CCF due to IHD were included for the study. The patients with the diagnosis of IHD but admitted for other clinical problems, patients with incomplete documentation were all excluded. The demographic information and risk factors were obtained and analyzed using SPSS 13.0 version. RESULTS A total 115 cases of Ischemic heart disease were admitted in Dhulikhel Hospital during 2008 and Review of Ischemic Heart Disease Patients admitted in Dhulikhel Hospital Mean age was 62.9 ± years with youngest being 34 and the oldest 94 years. Out of 115 cases, 62(54.8%) were males and 52 (45.2%) females (Male to female ratio was 1.19:1). Table1. Age distribution of patients. Age group Frequency Percent > Total Table2. Gender distribution of patients. Gender Frequency Percent Male Female Total Table3. Distribution of IHD patients among menopausal females compared to males of same age groups. Age Group Gender Total male female Less than 50 years More than 51 years Total P-Value < Female patients with IHD less than 50 years of age in later part of menstruation was less in number compared to male counterparts though it was statistically insignificant. Table 4. Risk factors according to sex. Risk Factors Male Female p-value Smoker 47 (75%) 29 (56%) < 0.05 Hypertension 17 (27%) 17 (33%) < 0.05 Diabetes 3 (5%) 8 (15%) NA Table 5. IHD patients from suburban region compared to rural. Place Male Female Total Suburban (40%) Rural (60%) 2

16 Review of Ischemic Heart Disease Patients admitted in Dhulikhel Hospital Among the identified risk factors for IHD, smoking was the most common followed by hypertension and diabetes mellitus. The smoking was significantly higher in males compared to female patients; whereas hypertension was similar in both groups. Diabetes mellitus was seen more with females; however, it was not statistically significant because of small number of patients. There was almost equal representation of patients from suburban (40%) and rural (60%) parts of the country. DISCUSSION IHD is a common public health problem in all parts of the world. Once thought a disease of the west and affluent society no longer holds true. The studies have shown the increasing prevalence of IHD in developing countries. In deed, some studies done in India have reported low socioecomic status defined by low educational status associated with greater risk of first myocardial infarction. 7 Some epidemiological studies have also reported greater prevalence of cardiovascular risks among the less educated and poor rural and urban subjects. 8,9 The studies concerning on these issues from Nepal are small and scarce. In this study of 115 patients with diagnosed IHD the mean age of the patient was 62.9+/ years which is quite similar to most of other studies. Another finding in this study is that the 7% of patients with IHD is below age 40, the youngest being 34 years of age. In a study by Shah et al in Nepal found upto 19.7% of patients out of 213 having first MI below 45 years of age; their mean age of first MI was 57+/_ 11 years lower than in our study. 10 In a large case-control INTERHEART multinational study, out of 1732 patients from south Asian countries the mean age of first MI was 53.0+/-11.4 years which was lower than from other countries. 11 These findings show that the IHD is becoming more prevalent even in younger age groups. The male to female ratio is 1.19:1. Out of 52 female patients 45 had IHD after age of 51 which correlates with the hormonal protective roles, 7 patients had before age 51; this could be correlated with the presence of other risk factors such as smoking and hypertension. Compared to male counterparts, the incidence of hypertension and diabetes were more in females (33 and 15%) respectively. In another study by Raut et al from Shahid Gangalal hospital found the similar results. Out of 283 MI patients, they found 53.3% and 32% of female patients having hypertension and diabetes associated respectively, which was greater than in male patients. The smoking as a risk factor was significantly higher in males than females (75% and 56%). In the study by Raut et al the smoking rate was 61.1% and 38.6% in males and females respectively. In our study, 60% of patients are from rural as against 40% from urban areas. This discrepancy could partly be explained on account of majority of patients who visit Dhulikhel hospital are from rural parts of the country. However, the figure underscores the fact that the number of IHD may be increasing even in the rural and poor socioeconomic status groups. The limitation of our study is that other major risk factors for IHD such as dyslipidemia and obesity were not included in this study. CONCLUSION Ischaemic heart disease is a common public health problem even in a rural part of Nepal and can affect younger age groups. Although, multiple risk factors are involved, the smoking and hypertension appear to be the most common and important risk factors for the IHD in this part of the country. Large scale effective preventive health campaign on these risk factors can help lower the incidence of IHD in the community. 3

17 Review of Ischemic Heart Disease Patients admitted in Dhulikhel Hospital REFERENCES 1. Murray CJL, Lopez A,. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to Cambridge, MA, Harvard School of Public Health on behalf of the World Health Organization and the World Bank, Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases, part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation 2001; 104: Murray CJL, Lopez AD. Global comparative assessments in the health sector. Geneva. Switzerland. World health Organization Dodu SRA. Emergence of cardiovascular disease in developing countries. Cardiology 1988; 75: Chuckalingam A. Balaguer- Vintro I. Impending global pandemic of cardiovascular disease. World Heart Federation. Prous Science. Barcelona, Spain Vaidya A, Pokharel PK, Nagesh S, Karki P, Kumar S, Majhi S. Prevalence of Coronary- Heart Disease in the Urban Adult Males of Eastern Nepal: A population-based analytical cross-sectional study. Indian Heart J. 2009; 61:34 7. Gupta R, Gupta KD. Coronary heart disease in low socioeconomic status groups in India: an evolving epidemic. Indian Heart J. 2007;59: In press. 8. Gupta R, Gupta VP, Ahluwalia NS. Educational status, coronary heart disease and coronary risk factor prevalence in a rural population of India. BMJ. 1994;309: Misra A, Pandey RM, Devi JR, et al. High prevalence of diabetes, obesity and dyslipidaemia in urban slum population in northern India. Int J Obes Relat Metab Disord. 2001; 25: Shah RK, Upadhya AB, Tibrewala LP, Regmi RR,Acharya KP,Khanal HH, Rajbhandari S, Shrestha D, Shrestha U, Pandey M.. Factors invoved in first myocardial infarction, its complications and thrombolytic pattern in selected hospitals in Nepal. Nepalese Heart Journal. 2008; 5: Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (The INTERHEART Study): Case control study. Lancet 2004; 364: Raut R,K.C. MB,Sharma D, Rajbhandari S, Baidya SG, Dhungana M, Pradhan M, Shrestha P, Bajracharya M. Comparative study of risk factors among the male and female patients with acute myocardial infarction admitted in CC of Sahid Gangalal National Heart Cectre. Nepaleses Heart Journal.2009; 6:4-7. 4

18 ORIGINAL ARTICLE Diagnostic Cardiac Catheterization for Congenital Heart Disease in Nepal Regmi SR*, Maskey A*, Dubey L*, Malla R*, Bhatt Y*, Rajbhandari R*, Limbu YR*, KC MB* *Shahid Gangalal National Heart Centre, Bansbari, Kathmandu ABSTRACT Accurate preoperative anatomic and functional diagnosis is of vital importance for surgical repair of congenital heart disease. The diagnostic accuracy of echocardiography alone in congenital heart disease is satisfactory but interventional catheterization is still required to derive the adequate information before surgical repair. This is a retrospective review of our early results with cardiac catheterization for congenital heart disease in Shahid Gangalal National Heart Center (SGNHC), Nepal. Keywords: Cardiac Catheterization, Congenital Heart Disease Correspondence: Dr Shyam Regmi Department of cardiology Shahid gangalal National Heart Center Kathmandu, Nepal 5

19 INTRODUCTION Accurate preoperative anatomic and functional diagnosis is of vital importance for surgical repair of congenital heart disease (CHD) 1. Cardiac catheterization and angiocardiography made it possible to derive adequate information for cardiac repair. Cardiac catheterization carries a risk especially in infants and in neonates. Recent technical advances in echocardiography provide the adequate information, even in the complex lesions, needed for cardiac surgery in many patients without invasive catheterization 2. So question arise whether catheterization is necessary before cardiac surgery in our setting where both echocardiography as well as catheterization are in the developing stages. This is a retrospective review of our early results with cardiac catheterization for congenital heart disease in SGNHC, Nepal. PATIENTS AND METHODS All children with CHD who underwent diagnostic cardiac catheterization between August 2003 and February 2010 were included and data was analyzed retrospectively. The need for cardiac catheterization was primarily determined by a cardiologist or suggested by a cardiac surgeon. Patient were initially evaluated by complete history, physical examination, chest X- ray, ECG and Diagnostic Cardiac Catheterization for Congenital Heart Disease in Nepal detailed echocardiographic examination. Before the procedure, a detailed explanation of purpose, route and possible complications were discussed with the patient party. Both written and informed consent were taken. Most of the cases were done under general anesthesia. Local anesthesia was used in older patients. Complete hemodynamic assessment with pressures, pulmonary vascular resistance, oxygen saturations and blood gas analysis as well as angiographic assessment were performed. RESULTS Table: Diagnosis of the patients who underwent diagnostic catheterization: During August 2003 to February 2010, we performed 1143 diagnostic paediatric cardiac catheterizations. Age ranges were from few weeks to 16 years. The most common indications for diagnostic catheterization was delineation of pulmonary artery anatomy, origin and course of coronaries, presence of significant sized MAP- CAs in tetralogy of fallot (TOF) in 405 (35.43%) and hemodynamic assessment for operability in patient with ventricular septal defect with severe pulmonary hypertension in 229 (20.03%). Other indications includes atrial septal defect with severe pulmonary artery hypertension (PAH) 154 (13.47%), PDA with severe PAH 47 (4.11%), primary pulmonary hypertension 35 Diagnosis Number of patients Percentage TOF VSD with severe PAH ASD with severe PAH PDA with severe PAH Tricuspid atresia Truncus arteriosus TGA Ebstein s anomaly AV canal defect with severe PAH DORV TOF with pulmonary atresia Congenitally corrected TGA Coarctation of aorta Primary pulmonary hypertension Others

20 Diagnostic Cardiac Catheterization for Congenital Heart Disease in Nepal Six (0. 53%) patients died immediately after procedure, 11 (0.96%) developed acute limb ischemia due to thrombosis at puncture site. Among the 405 TOF patients, right sided aortic arch was found in 142 (35.06%), anomalous coronaries in 119 (29.38%), significant sized MAPCAs in 222 (54.81%), inadequate PA size for intracardiac repair was found in123 (30.37%), (3.06%), tricuspid atresia 29(2.54%), truncus arteriosus 7 (0.67%), transposition of great arteries 41(3.58%), Ebstein s anomaly 3 (0.26%), AV - canal defect with severe PAH 24 (2.11%), DORV 65 (5.69%), TOF with pulmonary atresia 26 (2.27%), congenitally corrected TGA 8 (0.67%), two or more shunt anomalies 43 (3.77%), coarctation of aorta 19 (1.66%), total anomalous pulmonary venous drainage 6 (0.58%) and double outlet left ventricle 2 (0.17%). DISCUSSION Congenital heart disease is the single most important major congenital defect with prevalence of 8-10 per 1000 and is responsible for much mortality and morbidity in infants and children 3. Cardiac catheterization has proved its value as a major tool in the diagnosis of congenital cardiac defects 4. Some literatures demonstrated no advantage of cardiac catheterization over echocardiography in simple shunt lesions such as ASD, VSD and PDA 2, 5. However, there is controversy over whether cardiac catheterization is routinely indicated for preoperative diagnosis of more complex lesions. Echocardiography alone may be insufficient to obtain the anatomic and functional information needed for surgical repair in complex congenital heart disease and may require preoperative catheterization. We performed diagnostic cardiac catheterization in 1143 patients with congenital cardiac defects with low periprocedural mortality rate. Indications for catheterization were mainly delineation of pulmonary artery anatomy in patients with TOF, calculations of Qp/Qs and PVR in patients with left to right shunts with severe PAH to check for operability and delineation of anatomy in other complex CHD. These indications are not different from those reported by others. Catheterization is commonly indicated for hemodynamic assessment as it is not yet possible to measure accurately pulmonary artery pressure, Qp/Qs and PVR by echo. In conclusion, though diagnostic accuracy of echocardiography for safe cardiac surgery is increasing, cardiac catheterization is necessary to delineate pulmonary artery size, coronary anatomy, presence of significant MAPCAs and hemodynamic assessment for operability. REFERENCES 1. Stark J, Smallhorn J, Huhta J et al. Surgery for congenital heart defects diagnosed with cross-sectional echocardiography. Circulation 1983; 68: Krabill KA, Ring WS, Foker JE et al. Echocardiographic versus cardiac catheterization diagnosis of infants with congenital heart disease requiring cardiac surgery. Am J Cardiol 1987; 60: Zabal C, Lince R, Buendia A, Attie F, Rios MA. Interventional cardiology in congenital heart disease. Arch Inst Cardiol Mex 1999; 69: Inglessis I, Landzberg MJ. Interventional catheterization in adult congenital heart disease. Circulation 2007; 115: Freed MD, Nadas As, Norwood WI, Castaneda AR. Is routine preoperative cardiac catheterization necessary before repair of secundum and sinus venosus atrial septal defects? JACC 1984; 4:

21 ORIGINAL ARTICLE Effect of Oral Clonidine on Hemodynamic Response During Surgery Regmi BS*, Regmi SR*, Pradhan B*, Marahatta MN*, Dubey L* *Shahid Gangalal National Heart Centre, Bansbari, Kathmandu ABSTRACT Clonidine is an alpha 2-adrenoceptor agonist. It has recently, however, found a new and possibly significant role in anaesthesia and the treatment of pain. Diazepam has been used as a drug for premedication for years but oral clonidine has not been used as premedication even though it is cheaper and has longer postoperative analgesic effect. This prospective, double blind randomized study was conducted in department of anaesthesiology, institute of medicine, TUTH. A total 60 consecutive patients scheduled for abdominal gynaecological surgeries were randomized to clonidine or diazepam premedication group and received these drug one hour before surgery planned under spinal anaesthesia. Intraoperative haemodynamic changes in terms of blood pressure, heart rate, oxygen saturation, were recorded. Hypotension was occurred in 9(15%) in clonidine group and 10(16.7%) in diazepam group, (p value> 0.05). During surgery, bradycardia was noted in 6(10%) vs. 3(5%) patient in diazepam and clonidine group respectively (p value >0.05). Nausea, shivering, restlessness were other side effects seen during surgery in both clonidine and diazepam group (33.33% vs %). Although few more cases of nausea (1 vs. 5) with clonidine and few more cases of restless (3 vs. 7) were noted with diazepam, the overall difference was not statistically significant between two groups (p value >0.05). Oral clonidine premedication had similar hemodynamic response to diazepam. It is cheaper and has longer postoperative analgesic effect as well as similar sedative effect. Key words: Clonidine, intraoperative haemodynamic change, blood pressure Correspondence: Dr. Bharati Sharma Regmi, Department of Anaesthesia, SGNHC Phone: , bharututh@hotmail.com 8

22 INTRODUCTION Clonidine is an alpha 2-adrenoceptor agonist. It was synthesized in 1960s and has been used for over 20 years to treat hypertension. 1 It has recently, however, found a new and possibly significant role in anaesthesia and the treatment of pain. 2 Clonidine is a direct-acting alphaadrenergic agonist with a strong preference for the alpha-2 receptor. It acts centrally to produce inhibition of sympathetic vasomotor centers by inhibiting release of norepinephrine in the medulla. 3 Sympathetic tone is reduced, thus decreasing systemic blood pressure. 4 When used for the acute or chronic management of hypertension, the reduction in sympathetic tone decreases systemic vascular resistance, heart rate, and blood pressure. 5 Clonidine is rapidly and completely absorbed by the oral route, reaching peak plasma level in 60 to 90 minutes. 6 One of the major side effects of clonidine as an antihypertensive agent is its significant sedative property. 7 This is thought to be mediated by stimulation of alpha-2 receptors in the locus ceruleus, the area of the brain that modulates wakefulness. 8 This characteristic limits clonidine's use as an antihypertensive agent but is an attractive quality to the anesthesiologist due to its perioperative sedation. Its sedative effects, combined with anxiolysis and a favorable haemodynamic profile at low doses, makes clonidine a good preoperative medication. In fact, the anxiolytic effects of clonidine and benzodiazepines have been demonstrated to be comparable.9 Clonidine has the further advantage of producing sedation that is associated with only very small reductions in minute ventilation and no effect on hypercapnic or hypoxic respiratory drives. Thus it can be given in a relatively unmonitored environment such as a preoperative holding area. These central effects were also discovered to have advantages intraoperatively. 10 Clonidine attenuates sympathetically mediated hyperdynamic responses, making it a useful adjunct in patients at risk for myocardial ischemia. It can decrease the stress response to laryngoscopy as well as emergence from anesthesia and reduces perioperative catecholamine release overall. 11 Diazepam has been used as a drug for premedication for years but clonidine has not been used as premedication even though it is cheaper and has longer postoperative analgesic period. This Effect of Oral Clonidine on Hemodynamic Response During Surgery double blind, randomized study is designed to evaluate postoperative analgesic effect of oral clonidine premedication vs. oral diazepam premedication in spinal anaesthesia with hyperbaric 0.5% bupivacaine. This study was aimed to compare the intraoperative haemodynamic changes between oral clonidine and diazepam premedication in spinal anaesthesia with bupivacaine in abdominal gynaecological surgeries. MATERIALS AND METHODS After obtaining approval from institutional ethics committee, this prospective and randomized study was carried out in 60 ASA grade I and II patients scheduled for elective abdominal gynaecological surgeries in the operation theatre of Tribhuvan University Teaching Hospital (TUTH), Institute of Medicine, Maharajgunj, Kathmandu, Nepal since first Baisakh 2065 to first Falgun INCLUSION CRITERIA Patients of ASA I & II grading. All patients aged between years for elective abdominal gynaecological surgeries. Patients with controlled hypertension (BP<140/90mmHg) on antihypertensive drug other than clonidine. EXCLUSION CRITERIA Patients of ASA physical status more than II and contraindicated for neuraxial block. Concomitant intake of clonidine and /or diazepam. Patients with acute or chronic liver, renal disease. All patients were assessed one day before surgery as routine pre-anaesthetic check-up. The procedure, alternative methods and possible complications were explained to the patient in her own language. Informed and written consent was taken. All patients were premedicated with single dose diazepam 0.2mg /kg at bed time and advised for nil per orally from midnight the day before surgery. Patient was transferred to operation theatre preparation room on the day of operation. Base line blood pressure, heart rate and oxygen saturation were recorded. IV cannulation was done by 18G cannula. Patients were divided 9

23 randomly into two groups. Group 1 (clonidine ) and Group 2 (diazepam), each consisting of 32 patients. Randomization was accomplished by using sealed envelope method. Group 1 (clonidine) received 0.004mg / kg of oral clonidine and Group 2 (diazepam) received 0.2mg / kg diazepam as premedication one hour before subarachnoid injection with sip of water. Effect of Oral Clonidine on Hemodynamic Response During Surgery considered as heart rate <50/min, which was treated with atropine 0.3mg with incremental doses. Side effects like nausea, vomiting, shivering were managed with ondansetrone 8mg intravenously. The time interval between delivery of bupivacaine and patient received first dose of pethidine as analgesic was recorded. Systemic blood pressure, heart rate, ECG and SpO2 were monitored in operation theatre. Spinal anaesthesia was given and time of spinal anaesthesia delivered was recorded. Electrocardiogram, blood pressure and heart rate were monitored by the automated oscillographic method and were recorded every 5 minutes till the end of surgery. Hypotension was considered as a 20% decrease in baseline systolic BP or BP<80mmHg and was treated with mephentermine 6mg at incremental dose. Bradycardia was RESULTS A total number of sixty four patients were included in this study and were randomized to clonidine and diazepam premedication groups. Four patients were excluded, (one case converted to general anaesthesia due to inadequate level of block, two cases received opioid intraoperatively due to complaining of pain and fourth case excluded as the plan of surgery was changed). Therefore data of sixty patients was analyzed in this study. Table 1 Characteristics of the patient Clonidine Diazepam p value Mean + SD Age(Yrs) >0.05(NS) Mean + SD Weight (Kg) >0.05(NS) Mean + SD Baseline SBP(mmHg) >0.05(NS) Mean + SD Baseline DBP(mmHg) >0.05(NS) Mean + SD baseline HR (Per minute) >0.05(NS) Table-2 Distribution of subject according to ASA physical status. ASA Physical Status Group Patient ASA 1 ASA 2 Total p value Clonidine Number Percentage 40.0% 10.0% 50.0% diazepam Number Percentage 45.0% 5.0% 50.0% Total Number Percentage 85.0% 15.0% 100.0% There were higher number of ASA 2 status patients in clonidine premedication Group 6 than diazepam 3 but the difference was not statistically significant. p value (>0.05). 10

24 Table-3 Haemodynamic parameters (Hypotension) Group Patient Hypotension Yes No Total p value Clonidine Number Percentage 15.0% 35.0% 50.0% Diazepam Number Percentage 16.7% 33.3% 50.0% Total Number Percentage 31.7% 68.3% 100.0% Hypotension was occurred in 9(15%) in clonidine group and 10 (16.7%) in diazepam group, There is no significant difference between two groups. Chi square value is and p value 0.781(>0.05). Fig.1 Distribution of hypotension during surgery Effect of Oral Clonidine on Hemodynamic Response During Surgery 1= Clonidine Group 2= Diazepam group Table 4 Haemodynamic parameters (Bradycardia). Bradycardia (HR<50) Group Patient Yes No Total p value Clonidine Number Patient 5.0% 45.0% 50.0% Diazepam Number Percentage 10.0% 40.0% 50.0% Total Number Percentage 15.0% 85.0% 100.0% During surgery, bradycardia was noted in 6(10%) vs. 3(5%) patient in diazepam and clonidine group respectively. There is no significant difference between two groups. Chi square value is 0.52 and P value (>0.05). Hypertension and tachycardia were not noted in all 60 cases during surgery. 11

25 Table - 5 Side effects. Side effects Group Patients Nausea Shivering *No Side >1 side effects Restless effect Total p value Clonidine Number Percentage 8.3% 3.3% 33.3% 5.0%.0% 50.0% Diazepam Number Percentage 1.7% 5.0% 30.0% 11.7% 1.7% 50.0% Total Number Percentage 10.0% 8.3% 63.3% 16.7% 1.7% 100.0% *No side effects other than haemodynamic. Nausea, shivering, restlessness were other side effects seen during surgery in both clonidine and diazepam group(33.33% vs %), Although few more cases of nausea (1 vs. 5) with clonidine and few more cases of restless (3 vs. 7) were noted with diazepam, there is no significant difference between two groups. Chi square value is 5.57 and p value (>0.05). Table-6 Time of first dose analgesia. Group Mean(+SD) time of first dose of analgesia(min.) t-test p value Clonidine <0.001 Diazepam The mean+/- SD time of first dose analgesia was ( ) min in clonidine premedication group which was statistically significantly prolonged than diazepam premedication group ( ) minutes. p value < DISCUSSION Intrathecal clonidine has been shown to be effective in opioid-tolerant patients and has been used extensively in the treatment of chronic and intractable pain, neuropathic pain, and cancer pain. 12 Oral administration is both simpler and cheaper than intrathecal administration and is suitable for use as a premedication. Its sedative effects, combined with anxiolysis and a favorable haemodynamic profile at low doses, makes clonidine a good preoperative medication. In fact, the anxiolytic effects of clonidine and benzodiazepines have been demonstrated to be comparable.9 Clonidine has further advantage of producing sedation and prolongs postoperative analgesic period, decreases total post operative opioids consumption, but the major side effect, i.e. antihypertensive effect, limits its use as premedication agent. 13 Study showed pressure responses to noradrenaline and phenylephrine are enhanced by clonidine premedication. 14 In addition, previous studies Effect of Oral Clonidine on Hemodynamic Response During Surgery suggest that clonidine may also affect peripheral sensory nerves as a sole agent or in combination with local anaesthetics. 15 Clonidine premedication in a dose of 5 mcg/kg may be particularly well suited for elderly patients. To pursue this approach, sedation, intraocular pressure (IOP), and the hemodynamic profile of two doses of oral clonidine premedication were compared in 60 elderly patients, aged year, who underwent elective ophthalmic surgery under local anesthesia. Results suggest that a dose of 150 µg of clonidine, given orally min preoperatively to elderly patients is as effective as a dose of 300 mcg in decreasing IOP perioperatively, without causing excessive hemodynamic depression and sedation. 16 Clonidine easily crosses blood brain barrier and therefore may interact with alpha adrenergic receptors at spinal and supraspinal sites within the central nervous system. In addition previous studies suggest that clonidine may also affect peripheral sensory nerves as a sole agent 12

26 or in combination with local anaesthetics. 17 Premedication with 4-5 mcg/ kg oral clonidine was compared with mg/kg oral diazepam. Duration of sensory blockade by bupivacaine and fentanyl spinal anaesthesia as significantly prolonged in clonidine group. 18 The analgesic effect of clonidine is mediated by the same central alpha 2 adrenoreceptors that mediated its hypotensive effects. In our study, premedication with oral clonidine 4 mcg/kg was compared with oral diazepam 0.20 mg/kg for patients undergoing surgery under spinal anaesthesia with hyperbaric bupivacaine. Intraoperative haemodynamic changes were similar in both groups, but clonidine group had longer postoperative analgesic period. This result is consistent with the study done in 1992, by Ota K, Namiki K, Ujike Y & Takahashi I. They concluded that sensory analgesia of spinal tetracaine was prolonged by oral clonidine premedication because of its capacity to prolong sensory blockade & its potent sedating properties. 19 In our study, duration of sensory block following spinal anaesthesia with 0.5% hyperbaric bupivacaine was significantly prolonged when the patients were premedicated with oral clonidine. The result is consistent with the findings of study done by Singh H, George YG and Paul FW 20 in which oral clonidine prolonged the duration of tetracaine s sensory & motor block. Effect of Oral Clonidine on Hemodynamic Response During Surgery Some other studies showed patients treated with clonidine before and 24 hours after surgery had a larger reduction of anxiety and pain levels after surgery, reduced the heart rate perioperatively and enhanced sleepiness immediately after surgery. Bradycardia and hypotension are adverse effects of alpha 2-adrenergic agonists. However, these effects prevent tachycardia and hypertension. Risk of cardiac ischemia is reduced by blunting the sympathetic activity on the cardiovascular system after surgical stress and emergence from anesthesia 21. Thus, clonidine may be an alternative therapy in patients with cardiac risk factors who are undergoing noncardiac surgery. In this study, neither clinically significant hypotension nor use of larger doses of vasopressor drugs was observed. Clonidine decreases opioid use and lowers hormonal response while maintaining stable hemodynamics in patients undergoing CABG. These results suggest oral clonidine could be a better therapeutic alternative to other preoperative sedatives. Further studies are necessary to compare its effects with other anxiolytics on postoperative outcomes in other cardiac and noncardiac surgeries. CONCLUSIONS Oral clonidine premedication had similar hemodynamic response to diazepam. It is cheaper and has longer postoperative analgesic effect as well as similar sedative effect. Further studies are needed to support its use in coronary artery bypass and other orthopedic, paediatric and general surgeries. 13

27 Effect of Oral Clonidine on Hemodynamic Response During Surgery REFERENCES 1. Maze M, Tranquilli W. Alpha-2 adrenoceptor agonists: Defining the role in clinical anesthesia. Anesthesiology 1991; 74: Dobrydnjov I, Axelsson K, Gupta A, Lundin A, Holmström B, Granath B. Improved analgesia with clonidine when added to local anesthetic during combined spinal-epidural anesthesia for hip arthroplasty: a double-blind, randomized and placebo-controlled study. Acta Anaesthesiol Scand. 2005;49(4): Dobrydnjov I, Axelsson K, Samarütel J, Holmström B. Postoperat ive pain relief following intrathecal bupivacaine combined with intrathecal or oral clonidine. Acta Anaesthesiol Scand. 2002;46(7): Watanabe Y, Iida H, Tanabe K, Ohata H, Dohi S. Clonidine premedication modifies responses to adrenoceptors antagonists and baroreflex sensitivity. Can J Anaesth 1998; 45: Niemi L. Effects of intrathecal clonidine on duration of bupivacaine spinal anaesthesia, haemodynamics, and postoperative analgesia in patients undergoing knee arthroscopy. Acta Anaesthesiol Scand 1994; 38: Nishina K, Mikawa K, Shiga M, Obara H. Clonidine in paediatric anaesthesia. Paediatr Anaesth 1999; 9: Park J, Forrest J, Kolesar R. Oral clonidine reduces postoperative PCA morphine requirements. Can J Anaesth 1996; 43: Tanaka M, Nishikawa T. Oral clonidine premedication does not alter the efficacy of simulated intravenous test dose containing low dose epinephrine in awake volunteers. Anaesthesiology 1997; 87: N. Toshniwal, A. Halbe & H. Iyyer. Study of comparative effects of oral clonidine vs oral diazepam pre-medication on the extent and duration of sensory blockade in patients undergoing vaginal hysterectomy under spinal anaesthesia. The Internet Journal of Anesthesiology 2009 ; 19: Kock M, Gautier P, Fanard L. Intrathecal ropivacaine and clonidine for ambulatory knee arthroscopy: a dose-response study. Anesthesiology 2001; 94: Howie MB, Hiestand DC, Jopling MW, Romanelli VA, Kelly WB, McSweeney TD, Effect of oral clonidine premedication on anesthetic requirement, hormonal response, hemodynamics, and recovery in coronary artery bypass graft surgery patients. J Clin Anesth ;8(4): Filos KS, Goudas LC, Patroni O, Polyzou V. Hemodynamic and analgesic profile after intrathecal clonidine in humans. A dose-response study. Anesthesiology. 1994;81(3);: Ota K, Akiyoshi N,Yoshihito U, Ikuko T, Prolongation of tetracaine spinal anesthesia by oral clonidine. Anesth Analg 1992;75; Singh H, Geoge Y, Gaines W, White P. Effects of oral clonidine and intrathecal clonidine on tetracaine spinal block. Anesth Analg 1994;79; Bonnet F, Buisson VB, Francois Y. Effects of oral and subarachnoid clonidine on spinal anesthesia with bupivacaine. Reg Anesth 1990; 15: Maruyama K, Hongo T. Oral clonidine premedication exacerbates hypotension following tourniquet deflation by inhibiting noradrenaline release. J Nippon Med Sch 2004; 71(1): Inomata S, Yaguchi Y, Kihara S, Toyooka H. The effects of oral clonidine premedication on MAC and MAC for tracheal intubation (MAC-EI) of sevoflurane in children. Anaesthesiology 1998; 89: A Tanaka M, Nishikawa T. Effects of clonidine premedication on the pressor response to alpha adrenergic agonists. Br J Anaesth 1995; 75: Harron DW, Riddell JG, Shanks RG. Effects of azepexole and clonidine on baroreceptor mediate reflex bradycardia and physiological tremor in man. Br J Clin Pharmacol 1985;20: Mayson KV, Gofton EA, Chambers KG Premedication with low dose oral clonidine does not enhance postoperative analgesia of intrathecal morphine. Can J Anaesth. 2000;47(8): Abbas O, Mojgan J, Alieh Z, Maryam J, Ashrafi AT. Analgesic and antisympathetic effects of clonidine in burn patients, a randomized, double-blind, placebo-controlled clinical trial. Br J Anaesth 2007;

28 ORIGINAL ARTICLE Socio-economic Analysis and the Study of Prevalence, Awareness, Treatment, Control and Risk Factors of Hypertension in Hospital Staff Shakya S*, Bhattarai J*, Rawal K*, Kunwar AR*, Shakya YR*, Sharma D* *Shahid Gangalal National Heart Centre, Bansbari, Kathmandu. ABSTRACT Hypertension is an important public health challenge in the developing and the developed world alike. This worksite based descriptive cross-sectional study was undertaken in Sahid Gangalal National Heart Centre in 2010 with 50 subjects were recruited by multistage purposive cluster sampling. The primary aim of this descriptive cross-sectional study was to assess the socioeconomic status and to measure the prevalence, awareness, treatment, and correlates of hypertension. The prevalence of pre-hypertension is 38% and hypertension is 34%. Among the hypertensive 53% are aware of their condition and 66.66% of them are under treatment and 16.66% have control over the condition. The prevalence of overweight and obesity were 22% and 4% respectively. The prevalence of central obesity was 29.72% among male and 69% among female. Knowledge, Attitude and Practice on hypertension was satisfactory. Fourteen percent understood hypertension as a raised blood pressure during blood flow in the arteries. Majority of them (72%) have positive attitude towards use of medicine in hypertension. Majority of them (86%) had checked their blood pressure in last 2 years. Difference in prevalence of hypertension was found among the tobacco users and non- users (65% vs 40%), who do regular exercise and those who do not (28% vs. 38%) and sleep disturbance was higher among hypertensive than non-hypertensive (48% vs. 10%). Patients with Dislipidemia (32%) had higher prevalence of hypertension than those without Dislipidemia (44% vs 30 %) Similar finding were found between overweight participants (26%) and normal weight participants (46% vs 34%). The prevalence of hypertension is higher with the higher socio-economic status. Key Words: Socio-economic status, Hypertension, Risk factors Correspondence: Samjhana Shakya,Senior Staff Nurse Sahid Gangalal National Heart Centre Bansbari,Kathmandu, Nepal Phone Number: shakyasamjhana@gmail.com 15

29 Socio-economic Analysis and the Study of Prevalence, Awareness, Treatment, Control and Risk Factors of Hypertension in Hospital Staff INTRODUCTION Hypertension is one of the most important causes of cardiovascular morbidity and mortality. Globally, 7 million people die every year because of hypertension 1. About half of the world's burden of cardiovascular disease is carried by countries in the Asia- Pacific region. 2 In Nepal, the prevalence of hypertension was 6% in rural Kathmandu 3. One other study reported the prevalence of hypertension as 19.7% in the sub urban area of Kathmandu 4. Socioeconomic status is an important factor that determines the lifestyle, knowledge, attitude and practices of the people. It can have causative association and can interfere with treatment and treatment compliance.in developed countries socio economic condition is inversely associated with hypertension. However in low and middle income countries, section of the population that undergo more rapid social development are exposed to increased risk factors for CVD and thus are at a greater risk of disease compared to people who are less well off. 5 This is a descriptive cross-sectional study done at a worksite. The objective of this study is to assess the socio-economic status of the respondents, assess the prevalence, awareness, treatment, control and risk factors of hypertension in the study population. METHODS A worksite based descriptive cross-sectional study was undertaken in Sahid Gangalal National Heart Centre in 2010 with all the staffs working under Department of Administration and Department of Finance. A Total of 50 subjects were recruited by multistage purposive cluster sampling. Data was collected in two months of time period from January 2010 to February By nature data are both qualitative and quantitative. INTERVIEW Interview with each subject was done by using structured and unstructured questionnaire. Informed consent was taken from each participant. Measurement of Blood Pressure: Blood pressure (BP) measurement was carried out on each participant using standard mercury sphygmomanometers. BP was measured on both arms. Only the arm with higher BP was used for the second measurement. The first BP measurement was taken before the administration of the questionnaire and second BP measurement was obtained upon completion of the questionnaire. Mean Blood pressure was recorded on the basis of these two readings. Measurement of waist circumference: Waist circumference was measured according to the instructed by American Heart Association. Calculation of BMI: Height and weight was taken for each subject and BMI was calculated by weight in kg divided by height in meter square. RESULTS Demographic Features There were altogether 50 respondents, male 37(74%) and female13 (26%).The mean age of the respondent was 35.86years. Half of them had educated to less or equal to SLC and 48%had higher education. Majority of them live in single family (68%).Twelve percent were vegetarians. Alcohol consumption and smoking were 54%and 48% respectively. One third of them do regular exercise. Basic Anthropometric Measurement Mean height and weight of respondents were cm and Kg respectively. The prevalence of overweight and obesity were 22% and 4% respectively. The prevalence of central obesity was 29.72% among male and 69% among female. Prevalence, Awareness, Treatment and Control of hypertension The SBP ranges from mmHg and DBP ranges from mmhg. The average mean arterial blood pressure was 96.57mmHg.The prevalence of pre-hypertension was 38% and hypertension was 34%. Among the hypertensives, 53% were aware of their condition, 66.66% were on treatment and % of treated had controlled blood pressure. Among hypertensive, 88.24% were male and 16

30 Socio-economic Analysis and the Study of Prevalence, Awareness, Treatment, Control and Risk Factors of Hypertension in Hospital Staff 11.76% were female % are younger than 40 years. Knowledge, Attitude and Practice Seventy percent of respondents knew at least two or more symptoms of hypertension. Fourteen percent understood hypertension as a raised blood pressure during blood flow in the arteries. 28% could able to give the value of normal blood pressure. Majority of them (72%) have positive attitude towards use of medicine in hypertension. Majority of them (86%) had checked their blood pressure in last 2 years. Values of different parameters of hypertensive respondents (n=17) Parameters Percentage Central obesity High BMI Non Vegetarian Regular Exercise Education less than SLC Education more than SLC Job status : less than administrative assistant Job status : More or equal to administrative assistant Joint family The prevalence of hypertension seems high with higher education, higher job status and Joint family. DISCUSSION The prevalence of pre hypertension was 38% and hypertension was 34%. We compare these findings, with two community based studies conducted in Nepal and two worksite based studies done out of Nepal. Prevalence of hypertension in this study seems highest in compare to above study. We also found that the prevalence of pre hypertension has increased in many folds in this one decade. 6 As all the participants of this study are hospital staff their awareness was higher than community based study. Even though, awareness seems poor in compare to previous study. 7 Health seeking behavior on hypertension in this study was 67% compared to 26% in 2006 study. 8 It can be concluded that, definitely prevalence of pre-hypertension and the hypertension is increasing. Awareness, control and treatment rate is higher than community based study conducted in sub urban area in Kathmandu (4)but it is poor in compare to study had done in Salami Factory. 9 Knowledge, Attitude and Practice (KAP) on hypertension Overall health seeking behavior of participants was very good. All of them have heard about the hypertension and 86% of them have checked their blood pressure within last two years. More than half of them (58%) have given value for their last blood pressure. This figure is very good in compare to previous study when only 10% did so 10. Basic knowledge on hypertension was found very high. Seventy percentages of the participants knew at least two or more symptoms of hypertension. Only one of them said, hypertension only rarely causes any symptoms compared to 28% in above study. Overall, KAP on hypertension was satisfactory among the participants. It may be because they are heart hospital staffs; they are more knowledgeable in compare to general public. So, this data may not be representing general public s KAP on hypertension. Lifestyle and Hypertension No significant differences were found between vegetarians and non- vegetarians, amount of salt and oil consumption, frequency and amount of fruits and vegetables consumption, nature of their work and leisure activity. It may be because of 17

31 Socio-economic Analysis and the Study of Prevalence, Awareness, Treatment, Control and Risk Factors of Hypertension in Hospital Staff Comparison of findings on Prevalence, Awareness, Treatment and Control of hypertension Studies Indicators Sharma D(2006) Vaidhya (2007) Sankodi (2004) Capriotti (2000) Shakya (2010) Prevalence of hypertension 19.7% 22.7% 25.7% 30% 34% Pre-Hypertension * * * 11% 38% Awareness 41.1% * 61.5% 4% 53% Treatment 26% * * * 66.66% Control 6% * 21.9% * 16.66% inadequate subjects to prove it significant. Difference in prevalence of hypertension was found among the tobacco users and non- users (65% vs 40%), who do regular exercise and not (28% vs. 38%) and sleep disturbance was higher among hypertensive than non-hypertensive (48% vs. 10%). Hypertension and other factors Patients with Dislipidemia (32%) had higher prevalence of hypertension than without Dislipidemia (44% vs 30 %) Similar finding were found between overweight participants (26%) and normal weight participants (46% vs 34%). This is in accordance with previous findings (Shamail Zafar, 2007). CONCLUSION Over all the prevalence of pre- hypertension and the hypertension is probably increasing in Nepal. Awareness, control and treatment rate of hypertension is also improving. Overall, KAP on hypertension is satisfactory. Factors that were found to influence hypertension are tobacco use, regular exercise, concurrent diabetes, Dislipidemia and weight. This study was conducted with heart hospital staffs; it can be assumed that they are probably more knowledgeable in comparision to the general public, so, findings of this study may not be representing general public s KAP on hypertension. ACKNOWLEDGEMENT Our special thanks to the staffs of SGNHC, whose active participation and cooperation had given us an encouragement throughout the study. We have special debt of gratitude to Associate Professor Tilak Prasad Chaulagain for his valuable guidance. We would like to thank Mr. Siddhi Vinod Adhikari, Lecture TU, and Tri- Chandra Campus for his continuous support throughout the study. 18

32 Socio-economic Analysis and the Study of Prevalence, Awareness, Treatment, Control and Risk Factors of Hypertension in Hospital Staff REFERENCES 1. Burt VL, Cutler JA, Higgins SM, etal, Trends in the prevalence, awareness, treatment,and control of hypertension in the adult US Population. Journal of Hypertension 26(1): Masliniuk AL, lee CM, Lawes CM, Hypertension: Its prevalence and population attributable fraction for mortality from cardiovascular disease in the Asia pacific region, Journal of Hypertension 2007, Jan: 25(1), Pandey Mr, Upadhyaya LR, Dhungel S,1981. Prevalence of hypertension in a rural community in Nepal,Indian Heart Journal,Nov- Dec;33(6):284-9 Indian Heart Journal 4. Sharma D, KC M B, Rajbhandari S etal, Study of prevalence awareness, treatment and control of hypertension in Suburban area of Kathmandu, Nepal. Indian Heart Journal, Jan- Feb; 58(1): Vokonas PS, Kannel WB,Cupples La,1988. Epidemiology and risk of hypertension in the elderly : the Framingham study ; Journal of Hypertension6(1): Capriotti T, Kirby LG, Smeltzer SC 2000,unrecognized high blood pressure. A major public health issue for the workplace. AAOHB J,2000,Jul;48: Sonkodi B, Fodor JG, Abraham G et al2004. Hypertension screening in a salami factory:a worksite hypertension study, Journal of human hypertension,2004,18, Line Aubert, Pascal Bovet, Jean Pierre et al 1998 Knowledge, Attitudes and Practices on Hypertension in a country in epidemiological transition Journal of Hypertension,1998;31: Shamail Z, Israr Ul, Anjum R et al2007 Relationship of body mass index and waist to hip ration measurement with hypertension in young adult medical students,pakistan Journal of medical science, July-Sep2007, Vol 23, No 4, Vaidhy A; Pokhrel Pk, Karki P et al. Exploring the iceberg of hypertension a community based study in an eastern Nepal town. KUMJ 2007, 593:

33 ORIGINAL ARTICLE A study on major cardiovascular risk factors in Acute Coronary Syndrome (ACS) patient 40 years and below admitted in CCU of Shahid Gangalal National Heart Center. Adhikari CM*,Rajbhandari R*,Limbu YR*,Malla R*,Sharma R*, Rauniyar B*,Rajbhandari S*,Baidya S*,Sharma D*,Maskey A*,K.C MB* *Department of Cardiology, SGNHC, Bansbari, Kathmandu ABSTRACT Coronary artery disease (CAD), predominately manifest in older individuals, is a devastating disease precisely because an otherwise healthy person in the prime of life may die or become disabled without warning. When the afflicted individual is under the age of 40, the tragic consequences for family, friends, and occupation are particularly catastrophic and unexpected. Fortunately, the incidence of myocardial infarction (MI) and symptomatic CAD in young adults is low; most studies show that only about 3% of all CAD cases occur in this age range. Premature CAD is defined as cardiac events occurring before the age of 45 in men and 55 in women. In its severe form it is defined as CAD occurring below the age of 40 years. Prematurity and severity suggests that the disease starts at an early age and has a malignant course. In this study, we aim to investigate the major risk factor (smoking, Hypertension, Diabetes and dyslipidemia ) as defined by ACC-AHA pattern in ACS patient 40years or below admitted in Shahid Gangalal National Heart Centre (SGNHC) from April 2008 to April There were all together 54 ACS patients, male 44(81%) and female 10(19%). HTN is the risk factor which was more commonly diagnosed and treated, while Dyslipidemia, DM and IFG were not usually diagnosed in young patient before they were diagnosed CAD. Dyslipidemia was the most common comprising 83.3% followed by HTN 70%, smoking 70%, abnormal blood glucose level 50%, DM in 22.2% while IFG in 27.7 %. High total cholesterol (48%) is the common form of dyslipidemia followed by high LDL (44.4%), low HDL in 31.4%. When non modifiable risk factor family history is excluded, 85% of the patients have two or more risk factors of CAD. When smoking along with family history is excluded 94.5% of the patients have 1 or more risks factors for CAD. Keywords: acute coronary syndrome, risk factors Correspondence: Chandra Mani Adhikari Shahid Gangalal National Heart Centre, Bansbari,Kathmandu,Nepal Tel: , Fax: topjhap@hotmail.com 20

34 A study on major cardiovascular risk factors in Acute Coronary Syndrome (ACS) patient 40 years and... INTRODUCTION Coronary artery disease (CAD), predominately manifest in older individuals, is a devastating disease precisely because an otherwise healthy person in the prime of life may die or become disabled without warning. When the afflicted individual is under the age of 40, the tragic consequences for family, friends, and occupation are particularly catastrophic and unexpected. Fortunately, the incidence of myocardial infarction (MI) and symptomatic CAD in young adults is low; most studies show that only about 3% of all CAD cases occur in this age range. 1,2 Many early studies 3 evaluating these patients labeled them as having premature CAD. Premature CAD is defined as cardiac events occurring before the age of 45 in men and 55 in women. In its severe form it is defined as CAD occurring below the age of 40 years. Prematurity and severity suggests that the disease starts at an early age and has a malignant course. 4 It is now better understood as a rapidly progressive form of the disease. 5,6,7 A number of previous epidemiological studies have established the relationship between risk factors such as smoking, hypertension, dyslipidemia, and glucose intolerance and the occurrence of coronary artery disease (CAD). 8,9 A recent report from the World Health Organization has also demonstrated that smoking, high blood pressure (HTN),and dyslipidemia are the most important risk factors for CAD 10. Although there are few studies on risk factors in CAD patient but Till date there is no studies conducted regarding young CAD patients in Nepal. Thus in this study we aim to investigate the major risk factors in young ACS patients. OBJECTIVE The objective of this study was to investigate the major risk factor pattern in ACS patient 40 years or below. MATERIALS AND METHODS All ACS patients who are 40 years or below admitted in Cardiac Care Unit (CCU) of Shahid Gangalal National Heart Centre (SGNHC) from April 2008 to April 2009 were included in the Study. Patient who were diagnosed non- ST elevation Myocardial infarction (NSTEMI) or unstable angina (USA) need a significant stenosis in coronary angiogram (CAG) for inclusion. DATA COLLECTION All the data in this study were obtained from the hospital registry. Defining Cardiovascular Risk factors: Cardiovascular risk factors have been defined according to American College of Cardiology Key Data Elements and Definitions for Measuring the Clinical Management and Outcomes of Patients with ACS. 1. Family History of premature CAD: CAD in male first degree relative <55years; CAD in female first (degree relative <65years) 2. Smoking History confirming cigarette smoking 3. Dyslipidemia History of Dyslipidemia diagnosed and/or treated by physician. Or meets the criteria of National Cholesterol Education Program criteria: Total cholesterol (TC)greater than 5.18mmol/l; or Low-density lipoprotein (LDL) greater than or equal to3.37mmol/l; or High-density lipoprotein (HDL) less than 1.04mmol/l. 4. Hypertension (HTN): Hypertension as documented by: History of hypertension diagnosed and treated with medication of life style modification. Blood pressure greater than 140mmHg systolic and /or90mmhg Diastolic on at least 2 occasions 5. Diabetes (DM): History of DM,need for antidiabetic agents of fasting glucose greater than 7mmol/l. 6. Impaired Fasting Glucose (IFG) Fasting blood glucose between mmol/l. RESULTS 1. Demographic features There were all together 54 ACS patients, male 44(81%) and female 10(19%).Mean age 37years, youngest of 29 years.there were 36 STEMI, 21

35 A study on major cardiovascular risk factors in Acute Coronary Syndrome (ACS) patient 40 years and... 5 NSTEMI and 13 Unstable Angina patients. (Table 1) On the basis of prevalence of risk factors. Table 1: Demographic features of patients No. Percentage (%) Male/Female 44/10 81/19 STEMI NSTEMI USA Age Mean years 37 years 2. Distribution of CAD risk factors before and after admission Hypertension is the risk factor which was more commonly diagnosed and treated, while Dyslipidemia,DM and IFG were not usually diagnosed in young patient before they were diagnosed as having CAD.(Table 2)This shows that patient and physician were not aware in the diagnosis and management of risk factors. Table 2: Distribution of CAD Risk factors before and After Admission Risk Factor Diagnosed Diagnosed Before Treated after Admission Admission HTN DM/IFG 5/0 4/0 7/12 Dyslipidemia Family History 7-7 Smoking Distribution of CAD risk factors On the basis of prevalence of risk factors Dyslipidemia was the most common comprising 83.3% followed by HTN 70%, smoking 70%, abnormal blood glucose level 50%, DM in 22.2% while IFG in 27.7 %.( Table 3) Table 3: Distribution of CAD risk factors. Risk Factors No. of Patients Percentage (%) Family History Smoking HTN Dyslipidemia Abnormal Glucose DM IFG Types of Dyslipidemia In patient of ACS age 40years or below High total cholesterol (48%) is the common form of dyslipidemia followed by high LDL (44.4%), low HDL in 31.4%.Table 4 Table 4: Types of Dyslipidemia No. of Patients Percentage (%) High Total Cholesterol High LDL LOW HDL Distribution of Risk factors burden When we exclude the non modifiable risk factor family history, 85% of the patients have two or more risk factors of CAD. (Table 5) When smoking along with family history is excluded 94.5% of the patients have 1 or more risks factors for CAD. Table 6 Table 5: Distribution of Risk factors burden Risk factors No. of Patients Percentage (%) None One Two Three Four Table 6: Distribution of Risk factors burden (except smoking) Risk factors No. of Patients Percentage (%) None One Two Three DISCUSSION This is the first study conducted in this group of patient in our centre. There are few important finding in this study which could be very useful in the management of the risk factors in the young population. It is a known fact that study of CAD and its risk factors in young individuals is important in the current era of preventive cardiology. 11 Family history is a factor known to be present in many of these patients and probably represents a combination of risk factors that are genetically determined. 12 But in our study family history of CAD was not that frequent. Most of the 22

36 A study on major cardiovascular risk factors in Acute Coronary Syndrome (ACS) patient 40 years and... patients in our study are male which can easily be is most of the risk factors were not diagnosed explained by the fact that male gender is prone and treated before they are diagnosed to have to CAD. Cigarette smoking has been the single ACS. Though dyslipidemia is the most common factor most strongly associated with CAD in the risk factor but none of the patients were treated; it young adult 13,14 the relative risk for CAD was may just be because of the less attention given to about three times higher in smokers age 35 to 44, this risk factor. The interesting finding was most compared to nonsmokers. Smoking was not only of these patients have more than two risk factors. a prevalent risk factor, but its presence was an which suggest that the risk factor in these patient important predictor of long-term mortality regardless of treatment strategy. 15 Studies reported that occurs in clusters. between 76% and 90% of young patients with MI Numerous studies 19,20 have demonstrated the are smokers compared with 40% of older patients surprisingly good prognosis up to three years with MI 13,14 whereas our data suggest 70%of them after diagnosis of CAD in the young adult. But were smoker. Though smoking is a well known there is a huge impact in the mobidity and expenses in the therapy so there There is a need risk factor for CAD still many young people are smoking which may just be because of ignorance for identifying and correcting the conventional or inability to educate the public about its risk in risk factors like hypertension, diabetes mellitus, the development of CAD. Hypertension remains smoking, hyperlipidaemia, tobacco consumption, a standard risk factor associated with CAD. 16 and central obesity at much younger age. In our study HTN and smoking were present in 70%of the patient. As in our study abnormal CONCLUSION blood glucose and hyperlipidemia are frequently present in young CAD patients in other studies. Dyslipidemia, HTN and smoking were the most The importance of these factors in the pathogenesis of CAD and their powerful relationship factors occur in group in the young ACS patient. common risk factors in these patients. These risk to rapid disease progression is well documented These risk factors are not diagnosed and treated before the patient are diagnosed as ACS.As 17,18. Diabetes is found in only about 15% to 20% of all young CAD patients which is comparable management of risk factor is important aspect in to our data. 19 Our study clearly demonstrate that the primary prevention of CAD, everyone should Dyslipidemia, HTN and smoking were the most be aware about these risk factors and their diagnosis and treatment. But the important question common risk factors in these patients which clearly suggest that diagnosis and treatment of still remains unanswered at what age we should these risk factors are the most important in the start to screen and treat these risk factors as people at the age of twenty and thirty are presenting primary prevention of CAD in young population. with the ACS. The most interesting fact we found in our study 23

37 A study on major cardiovascular risk factors in Acute Coronary Syndrome (ACS) patient 40 years and... REFERENCES 1. Jalowiel DA, Hill JA. Myocardial infarction in the young and in women. Cardiovasc Clin 1989;20: Navas-Nacher EL, Colangelo L, Beam C, Greenland P. Risk factors for coronary heart disease in men 18 to 39 years of age. Ann Intern, Med 2001;134: Yater WM, Traum AH, Brown WL, Fitzgerald RP, Geisler MA, Wilcox B. Coronary artery disease in men eighteen to thirty-nine years of age. Am Heart J 1948;36: HS Rissam*, S Kishore*, N Trehan*Coronary Artery Disease in Young Indians The Missing Link Journal, Indian Academy of Clinical Medicine Vol. 2, No Sturzenhofecker P, Samek L, Droste C, Gohlke H, Petersen J, Roskamm H. Prognosis of coronary heart disease and progression of coronary atherosclerosis postinfarction in patients under the age of 40. In: Roskamm H, editor. Myocardial Infarction at Young Age. New York, NY: Springer-Verlag, 1982: Fournier JA, Sanchez A, Quero J, et al. Myocardial infarction in men aged 40 years or less: a prospective clinical angiographic study. Clin Cardiol 1996;19: Chen L, Chester M, Kaski JC. Clinical factors and angiographic patterns associated with premature coronary artery disease. Chest 1995;108: Castelli WP.Epidemiology of coronary heart disease:the Fram- ingham Study.Am J Med 76 :4-12, Hubert HB,Feinleib M,Mc Namara PM,Castelli WP.Obesity as an independent risk factor for cardiovascular disease:a 26-year followup of participants in the Framingham Heart Study.Circula-tion 67 : , WHO:Reducing risks,promoting healthy life. The World Health Report Jason H. Cole, Joseph I. Miller, III, Laurence S. Sperling, and William S. Weintraub Longterm follow-up of coronary artery disease presenting in young adults japan, J. Am. Coll. Cardiol,2003;41; Yater WM, Traum AH, Brown WL, Fitzgerald RP, Geisler MA, Wilcox B. Coronary artery disease in men eighteen to thirty-nine years of age. Am Heart J 1948;36: Chen L, Chester M, Kaski JC. Clinical factors and angiographic features associated with premature coronary artery disease. Chest 1995;108: Zimmerman FH, Cameron A, Fisher LD, Ng G. Myocardial infarction in young adults: angiographic characterization, risk factors and prognosis. (Coronary Artery Surgery Registry.) J Am Coll Cardiol 1995;26: Kannel W, McGee D, Castelli W. Latest perspectives on cigarette smoking and cardiovascular disease: the Framingham Study. J Card Rehabil 1984;4: HS Rissam*, S Kishore*, N Trehan*Coronary Artery Disease in Young Indians The Missing Link Journal, Indian Academy of Clinical Medicine Vol. 2, No. 16. Krolewski AS, Kosinski EJ, Warram JH, et al. Magnitude and determinants of coronary artery disease in juvenile onset, insulin dependent diabetes mellitus. Am J Cardiol 1987;59: H Klag MJ, Ford DE, Mead LA, et al. Serum cholesterol in young men and subsequent cardiovascular disease. N Engl J Med 1993;328: Nevas-Nacher EL, Colangelo L, Beam C, Greenland P. Risk factors for coronary heart disease in men age 18 to 39 years of age. Ann Intern Med 2001;134: Sturzenhofecker P, Samek L, Droste C, Gohke H, Petersen J, Roskamm H. Prognosis of coronary heart disease and progression of coronary atherosclerosis postinfarction in patients under the age of 40. In: Roskamm H, editor. Myocardial Infarction at Young Age. New York, NY: Springer-Verlag, 1982: Fournier JA, Sanchez A, Quero J, et al. Myocardial infarction in men aged 40 years or less: a prospective clinical angiographic study. Clin Cardiol 1996;19:

38 ORIGINAL ARTICLE Observational Study of Pulmonary Embolism Patients in Shahid Gangalal National Heart Centre Rauniyar B*, Adhikari CM*,Rajbhandari R*,Limbu YR*,Malla R*,Sharma R*, Rajbhandari S*,Sharma D*,Maskey A*,Singh S.K*,Prajapati D*,Joshi D*,K.C MB* *Department of Cardiology, Shahid Gangalal National Heart Centre, Bansbari, Kathmandu ABSTRACT Pulmonary thromboembolism (PE) is a relatively common cardiovascular emergency, with a significant mortality and morbidity often precipitated by deep venous thrombosis (DVT).It is considered as the third most common cardiovascular disorder after Acute Coronary Syndromes (ACS) and Stroke. This study aims to find out the clinical characteristic of Nepali PE patients. We hope that it can be helpful in the early recognition and management of PE patient. Eleven consecutive patients PE who were diagnosed based on CT report were studied. Predisposing factors were same as the other international study. Among eleven patients three were diagnosed as high risk pulmonary embolism, others were intermediate risk. Shortness of breath, chest discomforts are the commonest symptom. Echo revealed Dilated RA and RV were present in all patients. All the patients were treated with Heparin/Low molecular Heparin. Among the three high risk PE patients only one patient was treated with Thrombolytic therapy because of the missed diagnosis. The diagnosis is the most difficult and tricky part in the management of PE as treatment is the easiest part. Early suspicion is the most important part in the management of PE as symptom and sign are non-specific. Keywords: pulmonary embolism Correspondence: Chandra Mani Adhikari Shahid Gangalal National Heart Centre, Bansbari,Kathmandu,Nepal Tel: , Fax: topjhap@hotmail.com 25

39 INTRODUCTION Pulmonary thromboembolism (PE) is a relatively common cardiovascular emergency 1, with a significant mortality and morbidity often precipitated by deep venous thrombosis (DVT).It is considered as the third most common cardiovascular disorder after Acute Coronary Syndromes (ACS) and Stroke, with hospitalizations and deaths annually in US and as many as deaths annually in the European Union. 2,3,4 The true incidence of PE is unknown. Because its many non-specific clinical features it is one of the most difficult diagnostic challenges in all of medicine. 5,6 It has been reported, that only one third of patients dying with PE have a correct ante mortem diagnosis. 5 The diagnosis was never even made in most of these patients ante mortem. Although some patients die despite a correct and early diagnosis, Mortality is fourfold to six fold greater in those patients in whom the diagnosis was missed. Thus, there is continued interest in the accuracy of the clinical ante mortem diagnosis of PE. 7 Though small number of patient population we are trying to find out the clinical characteristic of Nepali PE patients. We hope that it can be helpful in the recognition and management of PE patient. METHODS Eleven consecutive patients who were treated in our cardiac center for PE were studied. The diagnosis was confirmed by CT. All the patient data in this study were obtained from hospital registry. RESULTS Clinical characteristics of the patients included in this study are shown in the table. The age range was between 31-68years. There were 8 male and 3 female patients. Among eleven patients three were diagnosed as high risk pulmonary embolism, eight were intermediate risk. Characteristics n=11 Age Observational Study of Pulmonary Embolism Patients in Shahid Gangalal National Heart Centre Male/Female 8/3 High risk PE 3 Intermediate risk PE years About the predisposing factors two have facture bone; cancer in one, recent surgery in one, remaining three patient don t have any predisposing factor. Predisposing factor Cancer 1 Recent Surgery 1 Bone fracture 2 CLINICAL PRESENTATION Nine of these patients presented to the ER. Nine cases were referred cases from other hospital with the diagnosis of ACS, only one patient was diagnosed as pulmonary embolism by the referring hospital. One patient presented to our ER and suspected to have PE on ECHO finding. Shortness of breath was present in all of them, chest discomfort in seven patients and syncope in three patients. Three patient presented in Cardiogenic shock. Sinus tachycardia was present in five patients.spo2 was less than 90% in six patients. Troponin I was positive in just a single patient. ECG ECG finding of the patient are as follows: ECG Finding T waves negative in V1-V4 8 S1 Q3 T3 pattern 2 Sinus tachycardia 5 Complete/incomplete RBBB 2 Normal 3 No of patients Chest X-ray Hampton humps in one patient all others have unremarkable finding in chest X-ray. Echocardiography Dilated RA and RV were present in all patients. Treatment All the patients were treated with Heparin/Low molecular Heparin. Among the three patients who were diagnosed as high risk pulmonary embolism and was supposed to be treated with Thrombolytic therapy only one patient was treated with it. Two high risk pulmonary embolism patients did not receive such therapy, as we could not diagnose them when they presented to us. They were treated in line of ACS initially. 26

40 Observational Study of Pulmonary Embolism Patients in Shahid Gangalal National Heart Centre Prognosis All the patients were discharged on Warfarin after few days of hospital stay. DISCUSSION This study is the first observational study on PE patients. As in the developed countries diagnosis of PE is usually delayed and missed. To make a confirmatory diagnosis of PE, CT is needed which is not only expensive but also not easily available. As the symptoms of PE are non-specific and confirmatory test not easily available unless the clinical feature are clearly in favor of PE then only patient are sent for the confirmatory test. This may be the reason behind delayed diagnosis. Most of the patients in our study were referred cases with the diagnosis of ACS and later diagnosed as PE; this suggests that earlier suspicion and diagnosis of the disease would largely help in the early management of the disease. In our population the predisposing factors are same like those in other international studies. Sudden onset of shortness of breath was the most common symptom in our patient like in other international studies 8. Chest discomfort along with shortness of breath was the common presenting symptoms in our patient. Though these symptoms are not specific but we consider that these symptoms should make us suspicious of PE unless explained otherwise. When we consider the usefulness of ECG in the diagnosis of PE, ECG findings in these patients are usually non-specific and many times they are suggestive of ACS which may be the reason why most of the patients were referred with the diagnosis of ACS. Though simple investigation such as chest radiography and ECG are often inadequate in the diagnosis but they are really useful in the evaluation of PE. 9,10 S1 Q3 T3 pattern is considered as the most specific ECG changes of PE but as in other studies they are not sensitive. Negative T waves in Leads V1-V4 a sign of RV strain is common in our study population, though this pattern can be a normal variant and an ECG changes of ACS. But it can help us to make a suspicion when the clinical findings are suggestive of PE. It is considered that bedside transthoracic echocardiography can provide some information to substantiate the diagnosis, 11 When ECHO finding of dilated RA and RV are considered along with predisposing factors, symptom and ECG findings, we can easily come close to the diagnosis of PE, as we have done it many times in our study. Among these eleven patients one of the patients was confirmed as PE, only on clinical background with the help of ECG and ECHO and managed with Thrombolytic agent without the report of CT. This is the first time we have successfully thrombolysed a PE patient without a confirmatory CT report in our center. This practice was done on the base of the ESC Guidelines on the diagnosis and management of acute pulmonary embolism. The diagnosis is the most difficult and tricky part in the management of PE as treatment is the easiest part. Thrombolytic therapy is the first-line treatment in patients with high-risk PE presenting with cardiogenic shock and/or persistent arterial hypotension 8. All the others patient can easily be managed with Heparin followed by warfarin with very good prognosis. CONCLUSION PE is a common cardiovascular emergency. Diagnosis of PE is tricky because of non-specific sign and symptom. Shortness of breath and chest discomfort is the common symptoms. Though ECG and chest x-ray has minimal role in the diagnosis but they can help us to make us suspicious about the diagnosis. ECHO can provide important information in the diagnosis of PE. Suspicion is the most important part to come to the diagnosis of PE. 27

41 Observational Study of Pulmonary Embolism Patients in Shahid Gangalal National Heart Centre REFERENCES 1. Roy PM, Meyer G, Vielle B, Le Gall C, Verschuren F, Carpentier F et al. Appropriateness of diagnostic management and outcomes of suspected pulmonary embolism. Ann Intern Med 2006;144: Bell WR, Simon TL. Current status of pulmonary thrombo-embolic disease: pathophysiology, diagnosis, prevention and treatment. Am Heart J 1982; 103: Lilienfeld DE, Chan E, Ehland J, et al. Mortality from pulmonary embolism in the United States: 1962 to Chest 1990; 98: Stavros V Konstantinides.Acute pulmonary embolism revisited: : Postgrad Med J). 5. Goldhaber SZ, Hennekens CH, Evans DA, et al. Factors associated with correct antemortem diagnosis of major pulmonary embolism. Am J Med 1982; 73: Anderson FAJ, Goldberg RJ, Hosmer DW, et al. A popula-tion-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism:the Worcester DVT Study. Arch Intern Med 1991;151: Lilibeth A. Pineda, Vasanthakumar S. Hathwar and Brydon J. B. Grant Clinical Suspicion of Fatal Pulmonary Chest:2001;120; ESC Guidelines on the diagnosis and management of Acute pulmonary embolism.european heart journal(2008)29, Hyers TN, Hull RD, Weg JG. Antithrombotic therapy for venous thromboembolic disease. Chest 1995; 108:335S. 10. Janata-Schwatczek K, Weiss K, Riezinger I, Bankier A, Domanovits H, Seidler D. Pulmonary embolism II. Diagno-sis and treatment. Semin Thromb Hemostas 1996;22: Come PC. Echocardiographic evaluation of pulmonary embolism and its response to therapeutic interventions. Chest 1992;101(suppl):

42 ORIGINAL ARTICLE Tricuspid Valve Infective Endocarditis In Drug Abusers : Clinical Features and Results of Surgical Treatment Medvedev A.P.*, Lashmanov D.I.*, Bhandari Krishna*, Chiginev V.A.*, Pichugin V.V.*, Zemskova E.N.* * Nizhny Novgorod State Medical Academy; Cardiac and Vascular Surgery Center, Nizhny Novgorod, Russia ABSTRACT The objective of this study was to evaluate the clinical features, diagnostic criteria and indications for surgery in patients drug abusers with tricuspid valve infective endocarditis (TVIE), and outcome of surgical treatment in these patients. From December 1999 to August patients (drug addicts) with TVIE were operated in the department of acquired heart diseases of Cardiac and Vascular Surgery Center, Nizhny Novgorod. 25 males and 10 females aged from 15 to 51 years were included in this study. 3 patients were re-operated due to recurrence of endocarditis. Biological prosthetic valve "Bio-Lab" was used in all patients. Intravenous drug abuse was the cause of the disease in all patients. Acute onset with hectic fever, shivering, profuse sweating, intoxication and development of multi-organ failure were the main clinical features of the disease. Embolism of the peripheral branches of pulmonary artery by septic embolus or micro thrombi were common symptoms. Ultrasound investigation played an important role in diagnosis of TVIE. It was the only criteria for the verification of the diagnosis in patients with fever of unknown origin until the appearance of valve damages and cardiac murmurs. All 35 (100%) patients underwent tricuspid valve replacement (TVR). 3 (8.57%) patients underwent redo TVR because of prosthetic valve endocarditis due to persistent intravenous drug abuse after surgery. The hospital mortality rate was 0%. Acute debut of the disease may be the first clinical feature of tricuspid valve infective endocarditis in drug abusers. Ultrasound investigation is important for early diagnosis and effective treatment. Surgical treatment is indicated in cases of ineffective antibiotic therapy and massive tricuspid valve damages. Tricuspid valve replacement by a biological prosthesis was the treatment of choice in these patients. The use of biological prosthetic valve had good clinical results with low thrombogenic risk and high resistance to infection. Key words: infective endocarditits, drug abusers, tricuspid valve replacement. Correspondence: Krishna Bhandari Contacts: corsugeon@mail.ru; Tel.: ; Fax : +7(831) ; Postal Address: Vaneeva street, 209, Nizhny Novgorod, area code , Russia. 29

43 Tricuspid Valve Infective Endocarditis In Drug Abusers : Clinical Features and Results of Surgical Treatment INTRODUCTION Isolated tricuspid valvular endocarditis is no longer rare; beginning from the 1970's, an increasing incidence in lesions of right chambers of the heart has been noted. In the 1990 s, the rate of infective endocarditis in intravenous drug abusers (drug addicts) has progressively increased, exceeding 5-6% 1, 33% of whom are younger than 25 years. The affection of the right chambers of the heart by an infectious process is a characteristic complication in drug addicts, especially among intravenous drug abusers and is encountered in 60% of cases in isolation, in 14% - in association with a left-sided involvement (bilateral endocarditis), and in 26% only left chambers are involved 2. Infective endocarditis of tricuspid valve (TVIE) differs from left sided endocarditis, and is characterized by high resistance to antibiotic therapy, atypical clinical features, and severe pulmonary lesions due to embolic complications, toxic-septic liver lesions, severe intoxication and sepsis, early development of multi-organ failure (MOF), recurrence of infection. Atypical clinical manifestations of TVIE cause late diagnosis, severe complications, and consequently inappropriate treatment. Even in confirmed cases, there is no standard treatment as this is a very new problem which has not been adequately elucidated in studies. OBJECTIVE The objective of this study was to evaluate the clinical features, diagnostic criteria and indications for surgery in patients drug abusers with tricuspid valve infective endocarditis, and outcome of surgical treatment in these patients. MATERIALS AND METHODS From December 1999 to August patients (drug addicts) with TVIE were operated in the department of acquired heart diseases of Cardiac and Vascular Surgery Center, Nizhny Novgorod. 25 males and 10 females aged from 15 to 51 years were included in this study. 3 patients were re-operated due to recurrence of endocarditis. The inclusion criteria for this study were: infective endocarditis of tricuspid valve with narcomania.12 patients were excluded from this study as they had infective endocarditis of other valves : aortic valve (7); mitral valve (2); mitral and aortic valves (2) and tricuspid valve and valve of pulmonary artery (1). We analyzed clinical features of the disease, biochemical investigations, chest x-ray, ECG, ultrasound investigation and CT as required. Blood cultures were performed. All patients were operated with cardiopulmonary bypass and crystalloid cardioplegia. Biological prosthetic valve "Bio-Lab" ("BioLab" is a product of Bakulev scientific and research centre for cardiovascular surgery, Russian Academy of Medical Sciences, Moscow, Russia) was used in all patients. Morphological evaluation of the excised tricuspid valve was performed. RESULTS Intravenous drug abuse was the cause of the disease in all patients. Acute onset with hectic fever, shivering, profuse sweating, intoxication and development of multi-organ failure were the main clinical features of the disease. Embolism of the peripheral branches of pulmonary artery by septic embolus or micro thrombi was a common symptom. Clinical manifestations of the disease are presented in the table 1. The majority of the patients (30 or 85.71%) were in IV functional class NYHA and only 5 (14.28%) were in III functional class NYHA. Twenty four patients (68.57%) had serious pulmonary complications as destructive pneumonia. Preoperative management of these patients was performed in pulmonary department. These patients were managed by physicians and cardiologists. Active effective antibiotic therapy reduced inflammatory changes in the lungs leading to improved respiratory function. Surgery was performed in patients unresponsive to medical therapy. Blood culture was positive in 35 (100%) patients, Staphylococcus aureus was found. Ultrasound investigation played an important role in diagnosis of TVIE. It was often the only critria for verification of the diagnosis in patients with fever of unknown origin until the appearance of valve damages and cardiac murmurs. Ultrasound 30

44 Tricuspid Valve Infective Endocarditis In Drug Abusers : Clinical Features and Results of Surgical Treatment investigation is an important method to diagnose the vegetations in tricuspid valve cusps. Vegetations more than 3mm can be revealed with ultrasound. According to some authors 3, 4, vegetations can be revealed by ultrasound only when duration of illness exceeds 6 weeks. Careful and detailed analysis of all clinical features, medical reports, results of biochemical and instrumental investigations are necessary for accurate and on-time diagnosis of TVIE. Definitely, the use of bactericidal antibiotics is a basic method for treatment of IE. Antibiotic therapy for Table 1 Clinical manifestations of tricuspid valve infective endocarditis in drug abusers Clinical Features Number of patients % Acute phase with the development of MOF Embolism of pulmonary artery with pulmonary infarction and abscess formation Hepatitis С Hepatitis В and С Diffuse glomerulonephritis Splenomegaly ESR >60mm/hr Exudative pericarditis Pleuritis Fig.1. ECHO, parasternal position with short axis: destruction of septal and anterior leaflets of TV, prolapsed fragments of leaflets (arrow) into RA (RA - right atrium; RV - right ventricle; AO - aorta). Fig.2. ECHO, apical four-chambered position - massive vegetations (arrow) on tricuspid valve leaflets (RV - right ventricle; RA - right atrium; LV - left ventricle; LA - left atrium). Table 2. Morphological changes of tricuspid valve in drug abusers Operative Findings Number of patients % Massive vegetations Destruction, rupture, perforation of cusps Cusps ulceration Chordae detachment Paravalvular abscesses Parietal endocarditis

45 Tricuspid Valve Infective Endocarditis In Drug Abusers : Clinical Features and Results of Surgical Treatment IE should be prolonged to get remission and to prevent relapse. Currently, early adequate and effective antibiotic therapy improves prognosis in IE. Unfortunately, this is not always possible in drug addicts because of difficulties in diagnosis, widespread microbial resistant strains and recurrence of the infective process. They have a high risk of severe damage of valvular structures with the development of heart failure, massive oscillating vegetations, pulmonary embolism, paravalvular spreading of infection, formation of abscesses and others changes. Surgical treatment is method of choice in these patients. The best way to solve this problem is development and improvement of surgical methods. Indications for surgical treatment were as follows: 1) ineffectiveness of antibiotic therapy and presence of massive oscillating vegetations on damaged leaflets of tricuspid valve; 2) tricuspid valve regurgitation (3-rd degree) and 3) recurrent episodes of pulmonary embolism with the development of destructive pneumonia. All 35 (100%) patients underwent tricuspid valve replacement. 3 (8.57%) patients underwent redo TVR because of prosthetic valve endocarditis due to persistent intravenous drug abuse after surgery. Intraoperative findings of changes of tricuspid valve are presented in the table 2. All patients were discharged from the clinic with uneventful postoperative recovery. The hospital mortality in our study group patients was 0%. DISCUSSION Due to the following features, IE among drug abusers is classified separately: atypical clinical features, pulmonary involvement with the development of pulmonary embolism, severe septic process and multi-organ failure, resistance to antibiotic therapy. At present, the following are the indications for operative management of TVIE among drug abusers: 1. intractable infectious process; 2. recurrence of pulmonary artery embolism and its risk; 3. progressive circulatory failure. The management of such patients is determined by response and duration of antibiotic therapy, adequate etiological treatment. Timing and indication of surgery requires experienced clinical judgment and is decided by the cardiologist. Identification of pathogenic agent is important to evaluate prognosis. Conservative management leads to mortality in patients with polyantibiotic resistant Staphylococcus aureus. Operation should be performed in ineffective antibiotic therapy and before development of pulmonary complications and valvular damage when S. aureus is isolated in blood culture. The important clinical features among patients with TVIE are presence of pulmonary complications: septic pneumonia, infarction-pneumonia, multiple staphylococcal destruction. Severe pulmonary complication such as abscess with pronounced respiratory failure limits to operative management. Surgery may be required when recurrent emboli are detected and medical treatment is ineffective. Surgical management of such patients gives sound results before the development of pulmonary embolism 5. That s why to formulate indication to surgical management - risk of development of pulmonary embolism; ultrasound plays a determining role. Massive (> l cm) mobile 32

46 Tricuspid Valve Infective Endocarditis In Drug Abusers : Clinical Features and Results of Surgical Treatment vegetations may cause serious embolic complications. Appearance and potential embologenic vegetations need individual evaluation, but it is understood that operation should be performed before the embolic event. In patients on inotropic support, with progressing cardiac failure surgical management should be considered. The progression of cardiac failure in patients with TVIE is not only due to destruction of TV but also due to toxic infectious and immune inflammatory damage of the myocardium. Early diagnosis and treatment of TVIE, minimizes the severe tricuspid regurgitation 11,12. We didn t use this type of surgical treatment. The surgical management of such patients includes cardiac chamber sanitation and tricuspid valve replacement. Valve replacement eliminates tricuspid valve regurgitation but risk of prosthetic endocarditis is a life-threatening complication in persistent intravenous drug abusers. Mostly redo operations are ineffective. That s why, it is concluded that medical management of prosthetic endocarditis is the treatment of choice among intravenous drug users. There are many controversies regarding tricuspid valve replacement in intravenous drug abusers. Mechanical prosthetic valves are rarely used in tricuspid position due to high risk of thrombosis associated with low velocity of blood flow in right heart chambers. The recommended range of INR is for mechanical prosthetic valve and this causes an increased risk of bleeding. In many countries access to INR control is limited. Biological prosthetic valves are more preferable in tricuspid position. The use of biological prosthetic valve in tricuspid valve surgery considerably minimizes postoperative risk of thrombosis and free from oral anticoagulants. This is confirmed in our clinical study with biological prosthetic valve Bio-Lab in surgery for TVIE in intravenous drug abusers. destruction of TV components and myocardium, thus allowing valve-sparing operations. Thus, severe heart failure is a late indication for surgery 6. There are few methods of surgical management of TVIE. Two-step operative management to the patients with septic clinical features is suggested. In first step, affected valve is excised and infective focus removed. During the second step valve replacement is performed 3-4 months after the sepsis has subsided 7, 8. Clinical studies have showed that two-step method can be used in critical patients with intractable septic process in the absence of pulmonary hypertension 9,10. Supporter of this method leads to high probability of reoperation - mortality rate after first step is 15% and after second step 25% due to long-standing CONCLUSIONS 1. Acute debut of the disease may be the first clinical feature of tricuspid valve infective endocarditis in drug abusers. 2. The ultrasound investigation is important for early diagnosis and effective treatment. 3. Surgical treatment is indicated in cases of ineffective antibiotic therapy and massive tricuspid valve damages. Replacement of tricuspid valve by biological prosthesis was the method of choice for the patients with tricuspid valve infective endocarditis. 4. The use of biological prosthetic valve had good clinical results with low thrombogenic risk and high resistance to infection. 33

47 Tricuspid Valve Infective Endocarditis In Drug Abusers : Clinical Features and Results of Surgical Treatment REFERENCES 1. Demin A. A, Drobisheva V. P., Velter 0. Y. Infective endocarditis among intravenous drug abusers//clinical medicine p Masters C. A., Saba J., Dassagangas J. et al. The t surgical treatment of infective endocarditis in drug addicts//european Heart Journal-1987-vol.8-suppl.3, p Storojhilov G. I., Kasatova Т. В., Butkevich О. M. Experience of ECHO use among patients with infective endocarditis//therapeutic achieve-1980, v-52, 10, p Gonska B.D., sold G., Kreuzer H. Dedeutung des echocardiographishen Vegatationsnachweses fur den klinischen Verlauf und die Prognose bie infection Endokarditis//Ztschr. Kardiol Bd.73-H.7-s Moisev V. S., Troyanova T.G., Milto A S. Infective endocarditis in drug addicts/zclinical medicine , p Shevchenko Y.L., Khabulava G.G Infective endocarditis of right heart chambers//saint- Petersburg-Science-1996, 170 p. 7. Arbulu A., Thorns N.W., chiscan A. et al. Total tricuspid valvectomy without replacement in the treatment of Pseudomonas endocarditis// Surg.Forum.-1971, vol.22, p.l Chandraratna P.A.N., Reagan R.B., Imaizumi T. et al. Infective endocarditis cured by resection of a tricuspid valve vegetation//ann. Intern. Med.-1978, vol.89, 4, p Turley K. Surgery of right-sided endocarditis valve preservation versus replacement //J. Card. Surg.-1989, vol.4, 4, p Louie E.K., bienizrz Т., Moore A.M. et al. Reduced atrial contribution to left ventricular filling in patients with severe tricuspid valvulectomy: A Doppler echocardiographic study//j. Amer. Coll. Cardiol -1990, vol.16, 7, p Evora PR., Brasil J.C., Elias ML. et al. Surgical excision of the vegetation as treatment of tricuspid valve endocarditis//cardiology -1988, vol.75, 4, p Arbulu A., Astaw J. Management of infective endocarditis: Seventeen years experience// Ann. Thorac. Surg.-1987, vol.43, 2, p

48 ORIGINAL ARTICLE Prevalence of Hypertension in Semi-Urban area of Nepal Koju R*, Manandhar K*, Gurung R*, Pant P*, Bedi TRS* *Department of Internal Medicine, Dhulikhel Hospital KUH ABSTRACT Hypertension is one of the major cardiovascular problems in middle and low income countries. There are few studies conducted in Nepal which shows significant number of hypertensive population in suburban area. Systematic random sampling from voter lists of all the members more than 18 years of age of Dhulikhel Municipality was done. 796 among 1150 sampled population were interviewed and their blood pressure was measured twice using mercury sphygmomanometer in standard method in their home. The average blood pressure was taken for study. Hypertension was defined as systolic blood pressure 140 mmhg and/or diastolic blood pressure 90 mmhg, and/or on antihypertensive treatment. Total number of study population was 796. Among them 490 (61.6%) were female and 306 (38.4%) were male with age ranging from 18 years to 88 years (mean 48.41±17.38). Overall prevalence of hypertension was 28.9% (male 28.8%, female 29%). The prevalence was increasing with age (11.1% in <30 years to 44.8% in >70 years). According to JNC 7, 29.1% were in Pre-hypertensive group. This study shows that Hypertension is significant in suburban area of Nepal. Key words: Hypertension, Blood Pressure, Prevalence, Nepal 35

49 Prevalence of Hypertension in Semi-Urban area of Nepal INTRODUCTION METHODOLOGY Cardiovascular disease is a major health problem throughout the world and a common cause of premature morbidity and mortality. The recent trend shows that cardiovascular disease is also becoming a major problem in low and middle income countries. The more prevalent infectious diseases and malnutrition in developing countries are going to be replaced by non-communicable disease in the near future. By the year 2020, noncommunicable diseases are expected to account for 7 out of every 10 deaths in the developing regions, compared with less than half at present 1. Hypertension, among cardiovascular disease is one of the major components of the non-communicable diseases. Hypertension is an established major risk factor underlying the epidemic of coronary and cardiovascular diseases in most developed countries, and it has been shown to be a major public health problem in many developing countries since the 1970s 2. The rate of hypertension and its complications are decreasing in developed countries whereas it is increasing in developing countries 3,4,5,6. Although hypertensive illness is more prevalent in urban areas, it is also seen in people of rural areas with low socioeconomic condition 6,7. Unfortunately the prevalence of hypertension is increasing worldwide but awareness, treatment and control rates are very poor 8. The objective of this study was to estimate the prevalence of hypertension according to the recent criteria for diagnosis and to determine the status of treatment and control of hypertension in suburban area - Dhulikhel municipality. This study was carried out in semi-urban area of Nepal - Dhulikhel in From the recent voters list obtained from municipality, total 1150 samples were selected by systemic random sampling. The sample populations were more than 18 years of age. Among 1150 sample size, 796 respondents were studied. Others were either out of home or unwilling to be participated. They were interviewed with structured questionnaire. Their blood pressure was measured using mercury sphygmomanometer with appropriate cuff size in standard method in their home. The blood pressure was measured two times on upper arm in sitting position in the interval of 30 minutes. The average blood pressure was taken for study. Hypertension was defined as systolic blood pressure 140 mmhg and/or diastolic blood pressure 90 mmhg. Those who were diagnosed previously and taking antihypertensive medication were also defined as hypertensive. The diagnosis and classification of hypertension was done according to the JNC-7 report 9. The data were analyzed using SPSS 11.5 software. RESULT Table 1: Number of study sample and prevalence of hypertension. Total number of study population was 796. Among them 490 (61.6%) were female and 306 (38.4%) were male. The age ranged from 18 years to 88 years with mean 48.41± Overall prevalence of hypertension was 28.9% (male 28.8%, female 29%). The prevalence was increasing with age. The prevalence among below 30 years of age was 19 out of 171 (11.1%) whereas it was 43 out of 96 (44.8%) in more than 70 years of age. Sex Number Percentage Prevalence of Hypertension Male % Female % Total % 36

50 Prevalence of Hypertension in Semi-Urban area of Nepal Figure 1: Figure showing prevalence of hypertension in different age groups Hypertensive Normal 0 < > 70 Figure 2: Pie chart showing classification blood pressure 29% 29% 42% Normal Prehypertensive Hypertensive Among study population, 69.9% of hypertensive patients were unaware of their hypertension. Only 18.3% of all were taking antihypertensive medications. Table 2. Risk Factors among study population Smoking Diabetes Normal 39.70% 3.20% Hypertensive 38.20% 7.10% Rate of smoking was similar among hypertensive and non hypertensives. Diabetes was higher among hypertensive (p <0.05) DISCUSSION The overall prevalence of hypertension in this study was 28.9% (male, 28.8%; female 30%). In a study done by Pandey et al in 1981, the overall prevalence was 5.98% in rural population of Nepal according to the 1978 WHO criteria for the diagnosis of hypertension ( BP 165/95 mmhg) 10,11. The prevalence of hypertension was significantly increased in latest study done in suburban area of Nepal by Sharma et al. in 2006 according to JNC 7 which showed the prevalence was 19.7% (22.2% in men and 17.3% in women, P<0.05) 12. Shrestha et el found the prevalence of 22.7% among urban population aged more than 40 years 13. Similar trends were found worldwide. In a meta-analysis, it has been found that prevalence of hypertension has increased by 30 times among urban population over a period of 55 years and about 10 times over a period of 36 years in India 14. Keamey et al analyzed worldwide hypertension prevalence data published from 1998 to 2002 which showed 26.4% (95% CI %) of the adult population in 2000 had hypertension (26.6% of men and 26.1% of women), and 29.2% were projected to have this condition by 2025 (29.0% of men and 29.5% of women) 15. In this study the one third of population 232 (29.1%) was Pre-hypertensive according to JNC 7. They have doubled the risk of developing hypertension in 37

51 Prevalence of Hypertension in Semi-Urban area of Nepal future. The prevalence of hypertension in China in adult population of 35 to 74 yrs was 27.2% in a recent study 16. In a study done in Thiruvananthapuram city in Kerala, the overall prevalence in adult population of more than 40 yrs was 54.5%8. In a study carried out in Pakistan, the prevalence of hypertension in urban and rural population was 22.7% and 18.1 % respectively 11. Walf Maier et al. showed the prevalence of hypertension in North America was 27.6% while it was 44.2% in Europe. The overall prevalence of hypertension in United States in was 28.6% 17. In Canada Tu K et al found that the age- and sexadjusted prevalence increased from per 1000 adults in 1995 to per 1000 in 2005, which was a relative increase of 60.0% 18. The reported prevalence of hypertension varied around the world, with the lowest prevalence in rural India (3.4% in men and 6.8% in women) and the highest prevalence in Poland (68.9% in men and 72.5% in women) 19. in our study, the number of hypertension is increasing with the advancing age, however the hypertension is 19% among less than 30 years age group. Regarding the awareness and treatment of hypertension in our study, only 31.1% of the hypertensive subjects were aware that they had hypertension. Only 18.3% of the hypertensive subjects were taking antihypertensive medication. Similar findings were found by other investigators as well. According to National Health survey of Pakistan, 70% of the hypertensive patients were unaware of the disease 20. In the study carried out in Kerala, India only 39% of the hypertensive individuals were aware of their condition, only 29% were treated with anti-hypertensive drugs and only 30.6% of the treated subjects had adequate control of blood pressure 8. Although smoking is one of the major risk factor associated with hypertension, it was found to be similar among both hypertensive and non-hypertensive group. Diabetes was significantly higher among hypertensive subjects. Shrestha et al found that hypertension was less common with normal plasma glucose than in those with diabetes (18.8% vs. 36.7%) 13. This study showed that the prevalence of hypertension is increasing trend in not only urban but also suburban area in Nepal. This trend is similar worldwide. With this increasing trend, the awareness is far less which warrants the poor control of blood pressure and more complications. The timely detection, lifestyle modification, treatment and prevention are all important to deal with the alarming situation of increased prevalence of hypertension. REFERENCES 1. Breithardt G, Eckardt L. The Global Burden of Cardiovascular Diseases. XXIst Annual Congress of the European Society of Cardiology Fuentes R et al. Hypertension in developing economies: a review of population-based studies carried out from 1980 to J Hypertens 18(5):521-9: Singh RB et al. Hypertension and stroke in Asia: prevalence, control and strategies in developing countries for prevention. J Hum Hypertens 14(10-11):749-63: Seedat YK. Hypertension in developing nations in sub-saharan Africa. J Hum Hypertens Oct-Nov;14(10-11):739-47: Lenfant C. Can we prevent cardiovascular diseases in low- and middle-income countries? Bull World Health Organ 79(10):980-2; discussion 983-7: Kumar V et al. Health status of the rural elderly. J Rural Health 17(4):328-31: Soylu A et al. Effect of socioeconomic status on the blood pressure in children living in 38

52 Prevalence of Hypertension in Semi-Urban area of Nepal a developing country. Pediatr Int 42(1):37-42: Zachariah MG et al. Prevalence, correlates, awareness, treatment and control of hypertension in a middle-aged urban population in Kerala. Indian Heart J. 2003; 55: Chobanian AV et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289(19): Pandey MR, Upadhyaya LR, Dhungel S, Pillaik K, Regmi HN, Neupane RP. Prevalence of Hypertension in a rural community in Nepal. Indian Heart Journal Nov-Dec. 33(6): Pandey MR. Hypertension in Nepal. Bibl Cardiol. 1987; 42: Sharma et al. Study of Prevalence, Awareness and Control of Hypertension in a Suburban Area of Kathmandu, Nepal. Indian Heart Journal.2006; 58: Shrestha UK, Singh DL, Bhattarai MD The prevalence of hypertension and diabetes defined by fasting and 2-h plasma glucose criteria in urban Nepal, Diabetic Medicine 2006, vol. 23, no10, pp [6 page(s) (article)] (22 ref.) 14. Gupta R. Meta-analysis of prevalence of Hypertension in India. Indian Heart J. 1997; 49: Kearney PM; Whelton M; Reynolds K; Muntner P; Whelton PK; He J Global burden of hypertension: analysis of worldwide data. Lancet 2005 Jan 15;365(9455): Gu D, Reynolds K, Wu X, Chen J, Duan X, Muntner P, et al; InterASIA Collaborative Group. The International Collaborative Study of Cardiovascular Disease in ASIA. Prevalence Awareness, treatment and control of hypertension in China. Hypertension 2002; 40: Hajjar I, Kotchen JM Kotchen TA. Hypertension: trends in prevalence, incidence, and control. Annu Rev Public Health. 2006;27: Tu K, Chen Z, Lipscombe LL Prevalence and incidence of hypertension from 1995 to 2005: a population-based study CMAJ May 20;178(11): Kearney, Patricia M; Whelton, Megan; Reynolds, Kristi; Whelton, Paul K; He, Jiang Worldwide prevalence of hypertension: a systematic review Journal of Hypertension January Volume 22 - Issue 1 - pp Health profile of the people of Pakistan. Pakistan Medical Research Council. Islamabad network publication service

53 ORIGINAL ARTICLE Study of Cerebrovascular Disease at Dhulikhel Hospital Pokharel B.R*, Pant P*, Gurung R*, Koju R*, Bedi T. R.S*, Pathak M* ABSTRACT A stroke is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. It is a medical emergency that requires rapid diagnosis and treatment. The availability of CT Scan has made it easier for early diagnosis and intervention. The aim of this study was to identify the risk factors (eg. hypertension, diabetes mellitus and cigarette smoking) commonly seen in patients admitted in the hospital with stroke along with age group, sex distribution, duration of stay in the hospital and the occupancy of stroke patients admitted in medical ward. A total of 51 stroke patient were admitted in medical ward in the review period. CT scan was used to differentiate hemorrhagic from ischemic stroke. Patients were analyzed in terms of risk factors (like hypertension, diabetes mellitus and cigarette smoking) along with age and sex. In case of ischemic stroke along with CT Scan, ECG, Echocardiography, Carotid Doppler was done accordingly. Out of 2307 total admissions in medical ward, 51 cases (2.2%) were stroke patients. Among the stroke cases, 59% constituted male and 41% female. Similarly around 25% of the total cases were Diabetic / Hypertensive both or alone, 35% of the total cases were smokers, 48.6% of the cases were in the age groups. 61% stayed in the hospital for 5 days or less. Cerebrovascular disease carries a lot of financial, physical, social and emotional implications. If we can address the modifiable risk factors, we can reduce the incidence of stroke. Key words: cerebrovascular disease, stroke Correspondence: Dr Babu Ram Pokharel Lecturer drbrpokh@gmail.com Kathmandu University hospital 40

54 Study of Cerebrovascular Disease at Dhulikhel Hospital INTRODUCT ION Risk factors for stroke include advanced age, hypertension (high blood pressure), previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, cigarette smoking and atrial fibrillation. 1 High blood pressure is the most important modifiable risk factor of stroke. Cerebro Vascular Accident (CVA) is a burden to medical practitioners as well as for the patient. If risk factors are evaluated and managed CVA can be avoided. CVA is becoming one of the leading causes of death. Stroke will soon be the most common cause of death worldwide. Stroke is the third leading cause of death in the western word after heart disease and cancer 2, and causes 10% of worldwide deaths. 3 The hallmark of stroke is abrupt onset of neurologic deficit that corresponds to interruption of vascular supply to specific brain tissue. Atherosclerotic vascular disease usually affects the large vessels. Diabetes mellitus and hypertension are known risk factor for CVA. The LDL particle present in diabetic persons is more atherogenic than non diabetic patient. It has been said that diabetes is equivalent to prior MI in terms of vascular disease. Prior TIA history is important in case of thrombotic stroke. Embolic source can from either cardiac or carotid in origin. 4 Common symptom in stroke is weakness, paralysis (one side of the body with partial or complete loss of voluntary movement or sensation in a leg or arm), there is possibility of speech problems and weak face muscles, causing drooling of saliva, and numbness or tingling. A stroke can affect balance, vision, swallowing, breathing and even cause unconsciousness. In cases of severe brain damage there may be deep coma, paralysis of one side of the body, loss of speech, followed by death. Permanent neurological deficit may occur even after recovery. Small infarcts are associated with poorly controlled hypertension or diabetes and have been found in several clinical syndromes, including contralateral pure motor or pure sensory deficit, ipsilateral ataxia with crural paresis, and dysarthria with clumsiness of the hand. 5 MATERIALS AND METHODS A hospital based study was carried out in medical ward in the review period (2008 June to 2009 June). The total number of patient admitted in medical ward was 2307, out of which 51 were stroke patient. These 51 patients were analyzed in the regard of risk factors (like hypertension, diabetes mellitus and cigarette smoking) along with age, sex and days of hospital stay. Almost all the patient attended had been subjected to CT Scan of head, ECG, Echocardiography and Carotid Doppler accordingly on need basis. RESULTS On the basis of the study of cerebrovascular disease done at Dhulikhel Hospital, CVA constituted about 2% of total number of patient admitted in medical ward in the review period (51 out of 2307). Reviewing the CVA in terms of sex distribution, it was found that male were more prone for stroke than female. Male accounted for 59% of total stroke patient admitted where as female accounted about 41% which almost correlates with the series from other countries as well. Smoking is one of the risk factor for CVA. Most of the smokers have a tendency of denying their smoking habit. Only 29.5% of the total CVA patient admitted that they are smoking currently, while 5.8% admitted that they smoked in the past. The study showed that around 35.2% of total cases have declared smoking whether in the past or the present habit. Table 1: patients Frequency of smokers in stroke Smoking Frequency Percent Yes No Left Non responders Total % The next most common risk factor for CVA is hypertension. On analyzing the history of CVA 41

55 Study of Cerebrovascular Disease at Dhulikhel Hospital patient admitted around 22% of the patient were hypertensive while 4% of the patient had both hypertension and diabetes. Table 2: Past medical history in stroke patients Past History Frequency Percent Non responders HTN HTN/DM No Seizure disorder Total The study showed the most vulnerable age for developing stroke is around years of age, in the review period around 49% of the total CVA patients were of this age distribution, followed by 71 years above and in between 31 to 50 years of age which constitute of around 19% of total patients each. The average hospital stay for the stroke patients is around 5 days which is 61% followed by 6-10 days (26%). Table 3: Duration of hospital stay Hospital Stay Frequency Percent to to to Missing Total DISCUSSION Stroke quite often regarded as struck by the hand of God. 1 In many cases stroke is preventable provided that the risk factors are treated timely. Once CVA develops it is a burden for the patients and the relatives. The residual neurologic damage after CVA makes the situation more difficult. As seen in the study about 2.2% of hospital admission belongs to CVA with an average stay of about 5 to 10 days. Most of the cases requires intense imaging and further tests which creates financial burden to the patients and their family members. During the course of treatment and after the discharge patients are physically handicapped and not able to carry out their day to day works. In fact many of the patients do have emotional problems like denial and depression. Many of the patients do not admit that they smoke. It requires a repeated questionings to find out their smoking and drinking habit. This is one of the habits which should be strongly discouraged. Men smoke more than women. However in Nepal women are exposed to indoor pollution mainly from household smoke exposure during cooking. Due to changes in social and economic condition of the people, changes in life style, changes in eating habits also contributed to increase incidence of hypertension and diabetes. The study showed around one fourth of stroke patients had hypertension or diabetes in combination or alone. Good control of hypertension and diabetes definitely decreases the stoke incidence. Stroke can occur at any age according to risk factors. The study showed fifth and sixth decade of life had high incidence CVA. It may be due increase incidence of hypertension in this age group. CONCLUSION Stroke cases are commonly seen in many people these days, it makes their life miserable and hard to manage day to day work for the patient and their family members. It needs a lot of financial, family, social and emotional support for the patient. There are factors which helps people to minimize the incidences like by avoiding smoking and drinking habit, proper control of blood pressure and diabetes to live a good and healthy life. 42

56 Study of Cerebrovascular Disease at Dhulikhel Hospital REFERENCES 1. Adams HP et al: Guidelines for the early management of patients with ischemic stroke: A scientific statement from the Stroke Council of the American Stroke Association. Stroke 34:1056, 2003 [PMID: ] 2. Feigin VL (2005). "Stroke epidemiology in the developing world". Lancet 365 (9478): doi: /s (05) PMID The World health report Annex Table 2: Deaths by cause, sex and mortality stratum in WHO regions, estimates for Geneva: World Health Organization 4. Kleindorfer D et al: Incidence and short-term prognosis of transient ischemic attack in a population-based study. Stroke 36:720, 2005 [PMID: ] 5. Lastilla M. Lacunar infarct. Clin Exp Hypertens Apr-May;28(3 4): [PMID: ] 43

57 ORIGINAL ARTICLE Initial Experience of Transesophageal Echocardiography in NAMS Bir Hospital Shah RK* *Department of Cardiology, NAMS, Bir Hospital, Kathmandu, Nepal ABSTRACT A retrospective study of patients undergoing trans esophageal echocardiogram was conducted in Bir Hospital, from April 2008 to March A total of 51 patients were included in the study. Among the 51 patients 29 (56.8%) were female and 22 (43.2%) were male. Mean age was 38 +/ (range years). The improved resolution and anatomic detail provided by TEE makes it such a powerful diagnostic tool. TEE is a safe outpatient procedure. Viscous two percent lidocaine topical anesthesia was adequate for the procedure. Common indication for TEE was to confirm Atrial septal defect and Left atrial clot. Complications of TEE were very few. In this study most common problems were nausea and vomiting in 22 cases (43.1%) during procedure. Sore throat was in 3 cases(5.8%) after the procedure. Ventricular premature contractions were seen in I case(1.9%). Key words: Transesophageal echocardiography, Transthoracic echocardiography Correspondence: Dr Ram Kishor Shah NAMS, Bir Hospital Post Box: 8011 Kathmandu,Nepal Tel: , Fax: rkshah40@ yahoo.com 44

58 Initial Experience of Transesophageal Echocardiography in NAMS Bir Hospital INTRODUCTION In 1976, Frazin and colleagues 1 first attached a single crystal M-mode ultrasound transducer to the tip of a cable for esophageal imaging. Since then, improvements in ultrasound technology coupled with miniaturization of transducers and the development of soft flexible tubing have led to a virtual exponential growth of transesophageal echocardiography (TEE). Multiplane transducer technology is the latest innovation in the rapidly changing field of TEE. It consists of a single array of crystals that is electronically or mechanically rotated about the long axis of the sound beam in a 180 arc, producing a circular continuum of tomographic, two-dimensional transverse and longitudinal images 2,3. The primary advantage of multiplane technology is the ease with which an uninterrupted series of adjacent images can be obtained with minimal needs for repositioning of the probe tip. Thus, after nearly a decade of multicentre experience and rapidly advancing probe technology, TEE has truly become a major part of the diagnostic and therapeutic armamentarium of a cardiologist. MATERIALS AND METHODS A retrospective study that was conducted in the department of cardiology of NAMS, Bir Hospital, Kathmandu from April 2008 to March 2010 AD. All patients with indications for the procedure were subjected to TEE. The instrument used was Toshiba Xario (PST 50 AT, 5 MHZ). The procedure was explained to the patient, and an informed consent was obtained from the subjects. All data were analyzed by using statistical package for social science (SPSS) version 10 for windows. INDICATIONS 1. As an adjunct to transthoracic echocardiography (TTE) when the quality of the latter is unsatisfactory4 (i.e. large patient, presence of a prosthetic valve, thoracic deformities, etc.) 2. When the transthoracic window to the heart is impeded or unobtainable (i.e. in the operating room, catheterization laboratory and intensive care unit, etc.) 3. For intraoperative evaluation, particularly when significant residual cardiac abnormalities (i.e. outflow tract obstruction, valve regurgitation or stenosis, intracardiac communication) are anticipated or suspected. 4. For intraoperative monitoring of ventricular function in patients with congenital heart disease undergoing non-cardiac surgery. 5. For guidance of interventional procedures during cardiac catheterization (i.e. balloon interventions, placement of transcatheter devices, radiofrequency ablation, etc.) 6. When vegetations or masses (which are poorly-imaged from transthoracic windows) are suspected to be present. CONTRAINDICATIONS TEE is an invasive procedure; thus, when the risk to patient health outweighs the benefit of the procedure, a contraindication (relative or absolute) exits 4, 5. Absolute contraindications: 1. Esophageal obstruction or stricture 2. Active gastrointestinal bleeding 3. Perforated viscus 4. Unrepaired tracheoesophageal fistula 5. Severe respiratory decompensation 6. Inadequate control of the airway Relative contraindications: 1. Esophageal varices 2. Esophageal diverticulum 3. Cervical spine injury or deformity 4. Oropharyngeal distortion or deformity 5. Post esophageal surgery 6. Severe coagulopathy Preparation : A careful history was obtained before performing the transesophageal echocardiographic examination. In addition to a thorough cardiovascular history, specific questions was asked regarding past esophageal injury or surgery, swallowing difficulty, gastrointestinal bleeding, medications (e.g., aspirin), and allergies to medications (e.g. lidocaine). To minimize the risk of aspiration during the procedure the patient had nothing by mouth for at least four hours and preferably six to eight hours before the procedure. The procedure was explained to the patient, and an informed consent was obtained 6. Topical anesthesia consisting of viscous lidocaine gargle was routinely used during the procedure. The Patient was advised not to 45

59 Initial Experience of Transesophageal Echocardiography in NAMS Bir Hospital take anything by mouth for 30 to 60 minutes after the procedure 4. The incidence of bacteremia (4% to 8%) and the risk of endocarditis with upper endoscopy are considered negligible in most published reports In the recent recommendations of the American heart Association 12, endoscopy with or without gastrointestinal biopsy is considered a low risk procedure in which endocarditic prophylaxis is not recommended. RESULTS A total of 51 patients were included in the study. Among the 51 patients 29 (56.8%) were female and 22 (43.2%) were male. Mean age was 38 +/ (range years) and majority of them had atrial septal defect. (Table 1) Diseases Table 1 Frequency Percent Atrial septal defect (ASD) Constrictive Pericarditis (CP) Left atrial clot (LA clot) Normal Pericardial cyst Prosthetic valve Right atrial Myxoma (RA Myxoma) Vegetation(s) Total Transesophageal Echocardiographic assessment of heart diseases. DISCUSSION In general TEE is performed when the information obtained by TTE is insufficient and to obtain better images when transthoracic images are inadequate. The proximity of the esophagus to the heart allows for improved visualization of many cardiac structures, particularity those that are posteriorly located 13. In reported series, the incidence of major and minor complications is 2% to 3% with most being minor complications 13,14. Major complications (death, esophageal perforation, significant arrhythmias, congestive heart failure, and aspiration) occur with a frequency of 0.3%, with a reported mortality of less than 0.01%. Reported minor complications include transient hypotension, hypertension (particularly with agitation), hypoxia, and arrhythmias (such as sustained ventricular tachycardia, nonsustained ventricular tachycardia, and transient atrioventricular block). Methemoglobinemia has been rarely reported due to the anesthetic spray and should be considered if cyanosis occurs. In this study, the most common problems encountered were nausea and vomiting which was seen in 22 cases (43.1%) during the procedure. Sore throat was noted in 3 cases (5.8%) after the procedure. Ventricular premature contractions were seen in one case (1.9%). The improved resolution and anatomic detail provided by TEE, as compared with TTE is what makes it such a powerful diagnostic tool. However, this can also lead to misinterpretation of normal structures, trabeculations in the atrial appendage can be mistaken for thrombi, and lipomatous hypertrophy of the inter-atrial septum may be incorrectly labeled as a mass, as can the Eustachian valve, The transverse and oblique sinuses can be mistaken for abscess cavities 15. These pitfalls are best minimized by the experience of the operator, but variations in anatomy may provide diagnostic dilemmas for even the most skilled echocardiographer. CONCLUSION TEE is a safe outpatient procedure. Viscous two percent lidocaine topical anesthesia was adequate for the procedure. Common indication for TEE was to confirm the presence of ASD and to detect LA clot. Complications of TEE were very few. Misinterpretations of normal structures are best minimized by the experience of the operator. ACKNOWLEDGEMENT I would like to express my sincere thanks to sister Durga, Srijana, Laxmi, Anita, Rajaram, Sarita and other staffs of cardiac unit, who were directly or indirectly involved in this study. 46

60 Initial Experience of Transesophageal Echocardiography in NAMS Bir Hospital REFRERENCES 1. Frazin L et al: Esophageal echocardiography, Cirulation 54:102, Seward JB et al: Multiplane transesophageal echocardiography: image orientation, examination technique, anatomic correlations, and clinical applications, Mayo Clin Proc 68:523, Pandian NG et al: Multiplane transesophageal echocardiography, Echocardiography 9:649, Fleischer DE, Goldstein SA: Transesophageal echocardiography: what the gastroenterologist thicks the cardiologist should know about endoscopy, J Am Soc Echocardiogr 3:428, Ament ME: Fiberoptic upper intestinal endoscopy in infants and children, pediatr Clin North Am 35:141, Fleischer DE: Monitoring the patient receiving conscious sedation for gastrointestinal endoscopy: issues and guidelines, Gastrointest Endosc 35:262, Botoman VA, Surawicz CM: Becteremia with gastrointestinal endoscopic procedures, Gastrointest Endosc 32:342, Leitch DG et al: Bacteremia following endoscopy, Br J Clin Pract 40:341, Norfleet RG et al: Does bacteremia follow upper gastrointestinal endoscopy? Am J Gastroenterol 76:420, Perucca PJ, Meyer GW: Who should have endocarditis prophylaxis for upper gastrointestinal procedures? Gastrointest Endosc 31:285, Shorvon PJ, Ey Kyn SJ, Cotton PB: Gastrointestinal instrumentation, bacteremia, and endocarditis, Gut 24:1078, DaJani AS et al: Prevention of bacterial endocarditis: a statement from the committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the young of the American Heart Association, JAm Med Assoc 264:2919, Cheitlin MD, et al. ACC/AHA/ASE 2003 Guideline update for the Clinical Application of Echocardiography: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am coll cardiol 2003;42; Douglas PS, et al. ACCF/ASE/ACEP/ASNC/ SCAI/SCCT/SCMR 2007 appropriateness criteria for transthoracic and transesophageal echocardiography. J Am call cardio 2007;50; Khanderia BK, Seward JB Tajik AJ. Critical appraisal of transesophageal echocardiography: limitations and pitfalls. Crit care clin 1996;12:

61 SHORT COMMUNICATION How to improve drug compliance in hypertensive patients Correspondence: Dr Abdul Rasheed Khan MBBS; MD; MESC; FACP Head of Cardiology Abbasi Shaheed Hospital Karachi Medical & Dental College Several recent, long-term outcome studies have clearly demonstrated the benefit of blood pressure reduction on reducing cardiovascular disease. These studies have shown that lower blood pressures are associated with greater reductions in cardiovascular disease, particularly in diabetic patients. Despite these findings, studies from the National Health and Nutritional Examination Survey (NHANES) and from the World Health Organization have indicated that less than one quarter of hypertensive patients worldwide are controlled for high blood pressure at the goal of 140/90 mm Hg. Inadequately controlled hypertension remains a risk factor for coronary artery disease. These poor blood pressure control rates may contribute to the disappointing reductions in coronary artery disease and the high incidence of congestive heart failure seen among hypertensive patients. The increasing incidence of end-stage renal failure seen among hypertensive patients may also be related to inadequately controlled hypertension. Obtaining optimal blood pressure control in hypertensive patients remains the most important issue in the management of hypertension. Despite the fact that there are more than one hundred drugs for the treatment of hypertension and that millions of Rupees are spent on the treatment, blood pressure control is achieved in less than one quarter of hypertensive patients. There are multiple reasons for these poor blood pressure control rates, but one of the most important remains patient compliance. A study performed in a group of patients who received free medical care in California showed that, after 1 year on antihypertensive treatment, less than one third of the patients were still taking their antihypertensive drugs, irrespective of the class of drug with which they were treated. In another survey of 37,643 patients with hypertension performed between October, 1992 and September, 1993 in the United Kingdom, it was reported that change of treatment or discontinuation of treatment occurred in 40%-50% of the patients within 6 months. Patient adherence to therapy must be improved 48

62 How to improve drug compliance in hypertensive patients if we are to impact blood pressure control. Patient compliance or adherence has been a major problem in the management of hypertension for as long as we have been treating this disease process. Although the development of drugs with more favorable side-effect profiles as well as the development of once-a-day agents has resulted in some improvement in patient compliance, it still remains an important issue in the management of hypertension. Physicians should refocus on issues that influence compliance in their management of this disease process. Many of the important issues influencing compliance can be corrected with the appropriate approach. Clearly the selection of well-tolerated drugs that can be dosed once daily is critical. The use of low-dose combination therapy as firstline treatment for a significant percentage of hypertensive patients may represent an important change in our management and may improve compliance rates. Achieving more rapid blood pressure control may also have some beneficial effects on patient compliance. In order to improve on the outcome in hypertensive patients, we will have to significantly improve patient, as well as physician, compliance. 49

63 SHORT COMMUNICATION "How I do it" Aortic Valve Replacement in case of Double Valve Replacement Correspondence: Dr Rabindra B. Timala Cardiac Surgeon Shahid Gangalal National Heart Center Bansbari, Kathamandu, Nepal Small aortic annulus is frequently found in patients undergoing aortic valve replacement, for patients with rheumatic aortic disease or elderly female with calcific aortic valve. All mechanical and stented bioprothesis have a smaller effective orifice area than that of a normal human aortic valve. The size of a valve prosthesis and body surface area of the patient has been reported as being important for late results. A small-sized valve prosthesis may cause residual obstruction of left ventricular outflow tract and interfere with regression of LV hypertrophy and clinical improvement and affect long term survival 1,2. Patient-prosthesis mismatch (PPM) is a feared complication of inserting smaller size aortic valve. The relationship between aortic valve area and mean systolic gradient is exponential. Because of curvilinear relationship between a prosthetic valve gradient and valve area, a relatively modest improvement in aortic valve area produces proportionately greater reduction in valve gradient. The valves that are on transition point of curve, small decrease in valve area may result in large increase in gradient (fig 1). Dumensil and Yoganathan showed that indexed "Effective Orifice Area"(EOA) greater than 0.85cm2. m2 will keep pressure gradient from rising during exercise, indexed EOA less than that considered to represent prosthesis-patient mismatch because of rapid rise in mean pressure gradient during exercise. 3 Relationship of mean systolic gradient to the aortic valve area, assuming the cardiac output and velocity of flow are constant.(from Rahimtoola SH.) The degree of regression of LV hypertrophy may be a sensitive indicator of adequacy of an implanted aortic prosthesis. Data from Sim and colleagues suggested that the regression of left ventricular hypertrophy was less in patients receiving a 19 mm stented bioprosthesis or mechanical valve compared with that in patients receiving larger valve sizes 4. It is likely that regression of left ventricular hypertrophy after AVR is associated with long term survival. Study from Mayo Clinic reported that patients receiving a 19 mm 50

64 How I do it Aortic Valve Replacement in case of Double Valve Replacement or 21 mm St Jude Medical prosthesis with average BSA of 1.76 m2, the prevalence of PPM was 60% ( 17% severe, 43% moderate), and severe PPM was found to be an independent predictor of higher long-term mortality and congestive failure. 5 Smaller prosthetic valve size has been associated with increased risk of mortality. The study by Kratz and colleagues suggested that patients with a BSA of greater than 1.9 m2 who received St Jude valve 19 mm or 21 mm had a greater probability of late sudden death 6. Aortic valve implantation. Mitral valve loosely kept inside left atrium. Pledgetts put outside aortic wall along non-coronary sinus for aortic valve. 51 Mitral valve (arrowed) implanted finally into the annulus. Various surgical techniques are described for insertion of larger prosthesis. The root enlargement techniques like Nicks or Manouguian procedure are associated with operative risk of bleeding, increasing clamp time and mortality. Moreover, there is limitation in enlargement when performing double valve replacement, because of close association of aortic & mitral annulus. Aortoventriculoplasty ( Konno procedure) is again a 'big'' procedure associated with morbidity and mortality.

65 The accepted classical technique in double valve replacement (DVR) is to implant mitral valve before aortic valve. This tradition comes from the fact that after inserting AV it will be difficult to visualize and put stitches along anterior mitral annulus. The problem of inserting mitral valve first is that it narrows the aortic annulus and downsizes the aortic valve to be inserted by at least one size, for eg. if aortic annulus is of 23 mm, after inserting mitral valve it will accept only 21 mm aortic valve. To circumvent this problem of aortic downsizing, I have started to implant aortic valve first. However, the trick here is to put pledgetts along the mitral annulus beforehand and then only implant aortic valve. So aortic annulus gets the size of the valve that it deserves. Then one can easily implant mitral valve. For better hemodynamic effect, I prefer to implant aortic valve (bicuspid, mechanical) in antero-posterior direction. With this technique, the only compromise if at all is to avoid implanting too big a mitral valve, for instance 31 mm. And while tying the pledgetts for mitral valve, its easier to tie those lying in anterior annulus first, which still is under excellent view. I prefer to put mitral valve in anatomical position, so that struts of mitral valve do not impinge upon aortic valve, which is already in position. This is fairly simple and highly reproducible procedure, yet gives an immense result. Even with aortic root enlargement, one cannot put more than 2-3 mm upsize valve in case of DVR. The same benefit is achieved here without added morbidity of bleeding & cross-clamp time. The fear of crowding too much in the annulus can be relieved to some extent by putting pledgetts outside the aortic wall along noncoronary sinus area. Patient-prosthesis mismatch is present after virtually every aortic valve replacement. In aortic stenosis, we are trying to trade severe native valve disease for mild or moderate aortic stenosis. And as pointed out earlier, the lesser the better. Though controversy surround whether a device used for aortic valve replacement can be too small for a patient and affect immediate and long term outcomes, it s wiser to use larger size valve whenever possible, if it can be achieved without costing too much for the patient. REFERENCE 1. 1.Rahimtoola SH. The problem of valve prosthesis-patient mismatch. Circulation 1978;58: Pibarot P, Dumesnil J. Patient-prosthesis mismatch and the predictive use of indexed effective orifice area: is it relevant? Cardiac Surg Today 2003; Dumensil JG, Yoganathan AP. Valve prosthesis hemodynamics and the problem of high transprosthetic pressure gradients. Eur J Cardiothoracic Surg 1992; 6:S Sim EK, Orszulak TA, Schaff HV, Shub C. Influence of prothesis size on change in left ventricular mass following aortic valve replacement. Eur J Cardiothorac Surg 1994; 8 (6): Mohty D, Maouf JF, Girard SE, et al. Impact of prosthesis-patient mismatch on longterm survival in patients with small St.Jude medical mechanical prosthesis in the aortic position. Circulation 2006; 113: Kratz JM, Sade RM, Crawford FA Jr, Crumbley AJ, Stroud MR. The risk of small St. Jude aortic valve prostheses. Ann Thorac Surg 1994 May; 57 (5):

66 PART II ABSTRACTS 53

67 ABSTRACT Surgery for Tetralogy of Fallot: Our Experience Navin C. Gautam, Srijan Shrestha, Yogeshwor M. Singh, Siddhartha Pradhan, Jyotindra Sharma, Apurba Sharma, Murari Raj Upreti, Jeju Nath Pokharel, Bhagawan Koirala Department of Cardiovascular Surgery and Department of Anesthesiology SGNHC, Bansbari, Kathmandu, Nepal. BACKGROUND Tetralogy of Fallot (TOF) is a congenital cardiac malformation characterized by underdevelopment of the right ventricular infundibulum with anterior and cephalad displacement of the infundibular septum and its parietal extension, associated with RV outflow stenosis. TOF is one of the commonest cyanotic congenital heart disease. Surgical Treatment modality for Tetralogy of Fallot in our centre is total correction as far as possible or palliative shunt procedures when ever ICR is not feasible due to inadequate Pulmonary artery size. METHODS AND RESULT Last hundred cases of Tetralogy of Fallot who had undergone total intracardiac repair by a single surgical team between 6/2064 and 07/2067 were evaluated in this study. Different approaches for repair of the lesions were assessed. Mean age of the patient was 8.56±7.6 years. Male: female ratio was 1.7:1. Overall in hospital mortality was 7 %. CONCLUSION Different surgical approaches to repair of TOF can be applied to specific surgical anatomy with satisfactory early outcome. 54

68 ABSTRACT Short term outcome of Double Valve Replacement with or without concomitant tricuspid repair in rheumatic patients below 15 years of age. Anil Acharya, Raamesh Koirala, Subash Pant, Uma Gurung, Purnima Rai, Sajal Uprety. *Department of Cardiovascular Surgery, SGNHC, Kathmandu, Nepal. BACKGROUND Rheumatic heart disease is still prevalent in developing countries and it is the main cause of valvular surgery in pediatric population. METHOD Here we present our experience of double valve replacement with or without tricuspid valve repair in pediatric population. RESULTS During in our unit, we have performed valvular surgeries for rheumatic lesions on 199 patients below 15 years of age and among them 65 (32.7%) had DVR. Two (3.1%) were below 10 years of age. Male: Female ratio was 2.1:1 and mean Body surface area (BSA) was m X m. Majority of them had regurgitant leasions. 88.8% were in NYHA III and IV. Mean LVIDs and LVIDd were cm and cm respectively. Ejection fraction was %. 14 patients underwent concomitant Tricuspid valve repair: 12 had Kay s annuloplasty and 2 had De Vega s annuloplasty. Total Cardiopulmonary bypass time and Aortic cross clamp time were minutes and minutes respectively. None had inhospital mortality and major complications postoperatively. Data were taken at 3 months (44 patients) and 12 months (32 patients) postoperatively. There was significant reduction in LVIDs and LVIDd at 3 months ( cm and cm) (p<0.05) and at 12 months ( cm and cm) (p<0.05). In patients who underwent tricuspid repair, 4 patients had significant tricuspid regurgitation postoperatively. The mean peak aortic valve gradient was mmhg at 3 months and mmhg at 12 months. CONCLUSION From this study we can conclude that double valve replacement can be performed even in pediatric population with acceptable outcome. However their growth will be a concern in future for potential patient-prosthetic mismatch. 55

69 ABSTRACT Premature Coronary Heart Disease in Nepal: An Evidence of a Rising Trend from a Hospital-Based Data Bharat Rawat, Rajeeb Shrestha, Parbati Gurung, Abhinav Vaidya, Shekhar Rajibhandari, Omika Sunuwar, Minalma Pandey, Farida Khatun, YD Bhatta *Norvic International Hospital, Thapathali, Kathmandu BACKGROUND Studies from South Asian countries have shown that coronary heart disease is affecting younger population more than it was previously thought to be. However, in Nepal, no study has been done to assess the prevalence of premature CAD (Coronary Artery Disease) or if there are certain risk factors more common in this specific group of patients. OBJECTIVE The study aimed to estimate the proportion of premature Coronary artery disease in the Nepalese population with established coronary heart disease. METHODS The study used an indirect method of estimation of premature CAD through the use of hospitalbased data of patients undergoing Percutaneous Transluminal Coronary Angioplasty (PTCA) at Norvic International hospital between 2002 and October RESULTS Out of the 863 Coronary Artery Disease patients who were treated with PTCA during the eight years period, 180 (20.9%) had presented at the age less than 50 years. Year-wise analysis of the data showed a rising trend for premature Coronary Artery Disease: from 15% in to about 25% in 2010 (till October end). Hypertension, tobacco addiction and dyslipidemia were more common in those with premature CAD. CONCLUSION The findings point out towards an alarmingly trend of Coronary Artery Disease in the younger population of Nepal thus necessitating the need for aggressive preventive programmes targeting the young population. 56

70 ABSTRACT Coronary Angioplasty Outcomes in the Elderly Nepalese Patients: A Nine year experience from a private Cardiac Centre of a developing country. Bharat Rawat, Chirag Gurung, Shekhar Rajbhandari, Yadav Dev Bhatta, Jay Prakash Jaiswal, Abhinav Vaidya, Minalma Pandey, Rajeev Shrestha, Pramila Rana *Norvic International Hospital, Thapathali, Kathmandu BACKGROUND The choice for finest treatment for coronary artery disease in the elderly has always been a difficult task given that the elderly patients have more risk factors and also face more side effects of the drugs. Percutaneous Coronary Intervention (PCI) as an option of treatment for coronary reperfusion has remained historically controversial. OBJECTIVE The aim of the study was to evaluate and compare the outcomes of PCI between the elderly (>70 yrs) and the non-elderly (70 yrs and younger) Nepalese patients who had been admitted to Norvic International Hospital between early 2002 and October METHODS Data of a total of 114 elderly and 749 non-elderly patients were retrospectively analyzed. Presence of risk factors such as hypertension, diabetes and dyslipidemia was noted. Outcome of the procedure was considered successful if a normal antegrade flow was noted after the procedure. Major complications included in-hospital death, sub/acute thrombosis, life-threatening arrhythmia (VT/VF) and minor complications included gastro-intestinal bleeding and groin hematoma formation, and need for blood transfusion. FINDINGS A total of 863 patients had undergone PCI between early 2002 and October There were 114 elderly (>70 years) patients while the remaining 749 were aged 70 years or younger. The elderly were less likely to be smokers, diabetic, dyslipidemic or with a positive family history. But they were more likely to be hypertensive. The proportion of females was considerably higher in the elderly group. The elderly patients slightly less success rate compared to the non-elderly (95.7% vs. 99.3%). Proportionately, there were more in-hospital deaths in the elderly group (7 % vs. 0.5%). The causes of death in the elderly were not directly related to PCI but rather due to more often diffuse Multiple Vessel Disease, the complications of the risk factors and other co-morbidities. Comparatively, minor complications were present more in the non-elderly group. CONCLUSION Treatment success with Percutaneous Coronary Invention of elderly patients can be safely performed with acceptable success rates. 57

71 ABSTRACT Comparison of Atherosclerotic severity and Procedural Success in Diabetic and Non-diabetic patients undergoing Percutaneous Coronary Intervention Bharat Rawat, Niranjan Gauchan, Farida Khatun, Yadav Dev Bhatta, Shekhar Rajbhandari, Jay Prakash Jaiswal, Rajeev Shrestha, Chandika Sunuwar, Laxmi Gurung, Omika Sunuwar, Pramila Rana, Dina Shrestha, Minalma Pandey, Abhinav Vaidya *Norvic International Hospital, Thapathali, Kathmandu BACKGROUND Percutaneous Coronary Intervention (PCI) is the most widely used treatment of modality for most of the coronary artery disease patients. Pre-PCI coronary angiography (CAG) can give a good insight to the number and severity of the culprit vessel(s). It can also be utilized to study if the presence of a strong atherogenic risk factor such as diabetes mellitus enhances the atherosclerotic severity of the disease. Also, diabetes is known to increase risk of various complications and adverse outcome with coronary revascularisation procedures. OBJECTIVE Norvic International Hospital began to do PCI since This study was conducted to compare angiographic findings of diabetic and nondiabetic patients with critical coronary artery disease undergoing PCI at the hospital between January 2002 and October In addition, the study analyzed the outcomes and complications of PCI in the diabetic and non-diabetic patients. METHOD This was a retrospective study of 863 patients who had undergone PCI between the nine years period. Data was collected from Cathlab database of all the patients who underwent coronary angiography followed by PCI. Standard nomenclature for angiographic descriptions and standard definitions for diabetic mellitus were followed. A stenosis of 70% or more was termed critical. RESULTS Of the 863 patients enrolled in this study, 318 (36.9%) were diabetic and the remaining 545 (63.1%) were non-diabetic. Coronary angiographic findings performed prior to PCI revealed that out of all the patients (n=863) most patients had critical single vessel disease (70.8 %) followed by double vessel disease (23.8 %) and triple vessel disease (5.4%). Diabetics had higher prevalence of double and triple vessel diseases compared to the non-diabetics (27.5% vs. 21.7% and 7.0% vs. 4.4% respectively) whereas single vessel disease was more common in the non-diabetics (65.6% vs. 73.9%) (p=0.033). In the combined group, commonly involved vessels with severe stenosis were: Left Anterior Descending artery (42.7%), Right Coronary Artery (33.9%), Left Circumflex Artery (29.5%) and Left Main coronary artery (0.4%). When analyzed separately, there was slightly higher prevalence of critical stenosis among diabetics compared to the non-diabetics: Left Anterior Descending artery (46.4% vs. 40.6%, p=0.060), Right Coronary Artery (35.1% vs. 33.3%, p=0.187), Left Circum- 58

72 Comparison of Atherosclerotic severity and Procedural Success in Diabetic and Non-diabetic patients undergoing PCI flex Artery (31.8% vs. 28.2%, p=0.182), Left Main coronary artery (0.4%, vs. 0.3%, p=0.991). Procedural success rates were similar among both diabetic and non-diabetic groups: 310 (97.48%) vs. 541 (99.26%). Complications of the procedure were however higher in the diabetic patients: In-hospital death (OR= 3.4, 95% CI: ), sub/acute thrombosis (OR= 0.8, 95% CI: ), and blood transfusion (OR= 1.7, 95% CI: ). CONCLUSION The study has shown that more widespread coronary artery disease in terms of number of vessels involved is observed in the diabetic patients. However, severity of atherosclerosis was not markedly high in the diabetic group, possibly because diabetic had remained under control in most of the diabetics. The immediate outcome of PCI was equally successful in diabetic and non-diabetic population groups. But the complications were higher with the diabetic group because of presence of other co-morbidities and were not procedure-related. Studies from other centers have also generally shown a comparable procedural success but higher in-hospital deaths among the diabetic cases. This confirms that diabetic patients with CAD remain a high risk group population and need a special attention despite initial successful PCI. 59

73 ABSTRACT First Six-years of Primary Percutaneous Coronary Intervention at Norvic International Hospital: Patient Profile, Procedural Efficiency and Follow-up Bharat Rawat, Shekhar Rajbhandari, Suvesh Kumar Shrestha, Jay Prakash Jaiswal, Yadav Dev Bhatta, Rajeev Shrestha, Chandika Sunuwar, Laxmi Gurung, Omika Sunuwar, Pramila Rana, Minalma Pandey, Parbati Gurung, Abhinav Vaidya *Norvic International Hospital, Thapathali, Kathmandu BACKGROUND Primary Percutaneous Coronary Intervention (PCI) is an emergency procedure in which angioplasty is done in Acute Myocardial Infarction (AMI) patient as soon as s/he arrives in the hospital. Norvic International Hospital that began PTCA in 2002 has been providing this often lifesaving service since OBJECTIVE The paper aims to present a profile of the patients that underwent primary PCI in the hospital between 2005 and 2009, evaluate the performance of the procedure both in terms of immediate complications and patient status in the follow-ups. METHOD A retrospective analysis of data of all the patients who underwent primary angioplasty in this hospital in between January 2005 till October 2010 was done. Demographic characteristics, coronary risk factors, angiographic findings, procedural details and immediate post-procedural outcomes and complications were recorded. In particular, Door-to-balloon-time (DTBT), which is a standard measure to determine how long it takes before a heart attack patient receives often lifesaving balloon (primary angioplasty) after reaching the hospital, was calculated. Patients were followed up within 3 months, 6 months and then on a yearly basis. Follow up questionnaire included status of patient s health including any major event such as myocardial infarction, stroke, revascularization, and death. FINDINGS One hundred and thirty two patients underwent primary angioplasty in the hospital in the six-year period. One hundred and twenty one (92%) patients were Nepalese and the rest (8%) were foreigners. The majority of them (86%) were males. A majority of the patients (60.60%) were in between years of age. Hypertension, dyslipidemia, smoking, positive family history and diabetes were present in 50%, 46%, 39%, 38% and 33% of the patients. About half of the patients (55 %) came with inferior wall myocardial infarction. Drug Eluting Stents were used in 72% of the patients. The coronary vessels treated were: Right Coronary Artery (49%), Left Anterior Descending (38%), Left Circumflex Artery (12%), and Left Main Artery (1%). 60

74 First six-years of PPCI at Norvic International Hospital: Patient Profile, Procedural Efficiency and Follow-up Overall procedural success was achieved in all but 2 (1.51%) cases. One death occurred due to possible mechanical complication after 4 hours of the procedure, while the other patient succumbed to VT/VF the following morning. There were no other major adverse cardiac events like cerebrovascular accident re-infarction, major bleed in other patients. Average annual DTBT between 2005 and 2009 were as follows: 2005 (N=5, 74.5± 2.3), 2006 (N=6, 72.2 ± 10.7), 2007(N=19, 65.3 ± 10.8), 2008 (N=24, 60.3 ± 8.2), 2009 (N=45, 45.8 ± 9.1) and 2010 (up to October) (N=33, 44.5 ± 9.4) minutes. The maximum door to balloon time was 95 minutes and the minimum was 23 minutes. Only two cases had the DTBT more than the recommended 90 minutes. One hundred and thirty patients were discharged successfully from the hospital. Among them, follow-ups could be completed as follows: 3 months (97/97, 100%), 6 months (88/97, 90.7%), 1 year (75/87, 86.2%), 2 years (36/44, 81.81%), 3 years (17/22, 77.27%), 4 years (4/10, 40%) and 5 years (0/4, 0%). One case of death was recorded within 3 months of the procedure due to sub-acute stent thrombosis. The remaining patients who could be followed-up were asymptomatic and doing normal activity. There were no reports of any major cardiovascular events such as ischemic attack or stroke in these patients. CONCLUSION The study gave an overview of the demographic, clinical and procedural characteristics of the patients that underwent primary PCI at Norvic International Hospital. Procedural efficiency parameters such as the DTBT achieved by the centre are in accordance with the ACC/AHA guideline. The follow-up study of these patients outlined a good success rate in terms of immediate complications and long term prognosis in the follow-ups which is comparable to the other centers abroad. 61

75 ABSTRACT Cardiac Auscultation Versus Echocardiography-Pilot Study on School Heart Survey Sunil Chandra Jha, Chandramani Poudel, Subarna Mani Acharya *Tribhuvan University, Institute of Medicine OBJECTIVE To detect RHD in clinically apparent and clinically silent cases and find out sensitivity and specificity of cardiac auscultation in the diagnosis of RHD and to determine the prevalence of RHD based on echocardiography. MATERIAL AND METHODS A Cross-sectional pilot study was carried out in Seven hundred and fifty eight students both male and female aged 5-16 yrs.five schools in Kathmandu Valley both in urban, urban slum and rural areas were selected for the study. Clinical examination was done by an experienced physician. Sex, height in meters, weight in Kg, socioeconomic status (SES) recorded in tabular form. All the students had screening echocardiography examination done. RESULTS On clinical examination 731 (96.43%) had normal cardiac findings on auscultation. Only 27 (3.56%) students had cardiac murmurs on auscultation. Of those students having cardiac murmur 15 had normal echocardiogram (55.55%) and only twelve had abnormal echo (44.4%). Presuming echocardiography as gold standard in diagnosing RHD, sensitivity of cardiac auscultation is 13.1% (7.9 to 20.7) at 95% confidence interval. 731 students out of 758 (96.43%) had normal cardiac findings on auscultation but 91 of them had evidence of RHD. Hence, the specificity of cardiac auscultation in diagnosing RHD is 96.7% (94.9 to 97.9) at 95% confidence interval. The predictive value of positive cardiac auscultation is 43.2% (27.5 to 60.4) at 95% confidence interval. The predictive value of negative cardiac auscultation is 85.3% (82.5 to 87.8) at 95% confidence interval. The p value for the sensitivity, specificity and predictive values is <0.01 which is highly significant. CONCLUSION 17.81% of school children screened have evidence of RHD on echocardiography % students having normal findings of cardiac auscultation had abnormal echocardiogram suggestive of RHD. Only 0.79% students who had cardiac murmur were positive for RHD on echocardiography. Sensitivity of cardiac auscultation in diagnosing RHD is 13.1% and specificity is 96.7%. Predictive value of positive cardiac auscultation is 43.2% and predictive value of negative cardiac auscultation is 85.3% thus, making cardiac auscultation as undependable tool for detection of RHD and echocardiography a very dependable tool for surveillance. 62

76 ABSTRACT Profile of Atrial Fibrillation in Nepal Guru Prasad S 1, Subramanyam G 2, Gautam MP 3 * Department of Cardiology, College of Medical Sciences KU Teaching Hospital Key words: Atrial fibrillation; Anticoagulation; Clinical profile BACKGROUND The conventional causes and risk factors for atrial fibrillation are somewhat arbitrary; overlap exists, multiple etiologies are often present in one individual, and clinical presentation is non-specific. This study is an attempt to study the clinical and echocardiographic profile of patients with AF in a tertiary care super-specialty hospital of a developing country. METHODS This study was conducted in College of Medical Sciences, Chitwan, Nepal during first 6 months of Subjects with AF, diagnosed based on surface ECG, were included in the study. The causes of AF and structural as well as functional abnormalities as shown by transthoracic echocardiography were recorded. RESULTS ranging from 17 to 80 years. Rheumatic heart disease was the most common cause (29.41%) followed by lone atrial fibrillation (23.52%), coronary artery disease (17.64%), hypertension (13.23%) and cardiomyopathy (7.35%). Other causes included COPD (5.88%), WPW syndrome (1.47%), constrictive pericarditis (1.47%) and tricuspid valve infective endocarditis (1.47%). Nearly 65 % subjects had either structural or functional abnormalities in echocardiographic study and remaining patients had normal echo study. CONCLUSION In contrast to the studies reported from developed nations, our subjects with AF were younger, the most common condition was RHD and the majority had either structural or functional abnormalities in echocardiographic study. A total of 68 consecutive subjects were included in the study. The mean age was 32 (20) years 63

77 ABSTRACT A study on major cardiovascular risk factors in Acute Coronary Syndrome (ACS) patient 40years and below admitted in CCU of Shahid Gangalal National Heart Center Adhikari CM, B Rauniyar, Rajbhandari R, Limbu YR, Malla R, Sharma R, Rajbhandari S, Baidya S, Sharma D, Maskey A, K.C MB *Department of Cardiology, Shahid Gangalal National Heart Centre, Bansbari, Kathmandu OBJECTIVES Coronary artery disease (CAD), predominately manifest in older individuals, is a devastating disease precisely because an otherwise healthy person in the prime of life may die or become disabled without warning. Premature CAD is defined as cardiac events occurring before the age of 45 in men and 55 in women. In its severe form it is defined as CAD occurring below the age of 40 years. Prematurity and severity suggests that the disease starts at an early age and has a malignant course. Numbers of previous epidemiological studies have established the relationship between risk factors such as smoking, hypertension, dyslipidemia, and glucose intolerance and the occurrence of coronary artery disease (CAD). Although there are few studies on risk factors in CAD patient but till date there is no studies conducted regarding young CAD patients in Nepal. Thus in this study we aim to investigate the major risk factors in young ACS patients. MATERIALS AND METHODS All ACS patients who are 40years or below admitted in Cardiac Care Unit (CCU) of Shahid Gangalal National Heart Centre (SGNHC) from April 2008 to April 2009 were included in the Study. Patient who were diagnosed non- ST elevation Myocardial infarction (NSTEMI) or unstable angina (USA) need a significant stenosis (more than 50%) in coronary angiogram (CAG) for inclusion. RESULTS There were all together 54 ACS patients, male 44(81%) and female 10(19%).Mean age 37years, youngest of 29years.There were 36 STEMI, 5 NSTEMI and 13Unstable Angina patients. HTN is the risk factor which was more commonly diagnosed and treated, while Dyslipidemia,DM and IFG were not usually diagnosed in young patient before they were diagnosed CAD. Dyslipidemia was the most common comprising 83.3% followed by HTN 70%, smoking 70%, abnormal blood glucose level 50%, DM in 22.2% while IFG in 27.7 %. High total cholesterol (48%) is the common form of dyslipidemia followed by high LDL (44.4%), low HDL in 31.4%.When the non modifiable risk factor family history is excluded, 85% of the patients have two or more risk factors of CAD. When smoking along with family history is excluded 94.5% of the patients have 1 or more risks factors for CAD. CONCLUSIONS Dyslipidemia, HTN and smoking were the most common risk factors in these patients. These risk factors occur in group in the young ACS patient. These risk factors are not diagnosed and treated before the patient are diagnosed as ACS.As management of risk factor is important aspect in the primary prevention of CAD, everyone should be aware about these risk factors and their diagnosis and treatment. But the important question still remains unanswered at what age we should start to screen and treat these risk factors as people at the age of twenty and thirty are presenting with the ACS. 64

78 ABSTRACT Observational Study of Pulmonary Embolism Patients in Shahid Gangalal National Heart Centre Adhikari CM, Rauniyar B, Rajbhandari R, Limbu YR, Malla R, Sharma R, Rajbhandari S, Sharma D, Maskey A, Singh S.K, Prajapati D, Joshi D, K.C MB *Department of Cardiology, SGNHC, Bansbari, Kathmandu OBJECTIVES Pulmonary thromboembolism (PE) is a relatively common cardiovascular emergency, with a significant mortality and morbidity often precipitated by deep venous thrombosis (DVT).It is considered as the third most common cardiovascular disorder after Acute Coronary Syndromes (ACS) and Stroke. Because its many non-specific clinical features it is one of the most difficult diagnostic challenges in all of medicine. It has been reported, that only one third of patients dying with PE have a correct ante mortem diagnosis. Though small number of patient population we are trying to find out the clinical characteristic of Nepali PE patients. We hope that it can be helpful in the recognition and management of PE patient. MATERIALS AND METHODS Eleven consecutive patients who were treated in our cardiac center for PE were studied. The diagnosis was confirmed by CT. All the patient data in this study were obtained from hospital registry. was diagnosed as pulmonary embolism by the referring hospital. One patient presented to our ER and suspected to have PE on ECHO finding. Shortness of breath was present in all of them, chest discomfort in seven patients and syncope in three patients. Three patient presented in Cardiogenic shock. Sinus tachycardia was present in five patients.spo2 was less than 90% in six patients. Troponin I was positive in just a single patient. Dilated RA and RV were present in all patients. All the patients were treated with Heparin/ Low molecular Heparin. Among the three patients who were diagnosed as high risk pulmonary embolism and was supposed to be treated with Thrombolytic therapy only one patient was treated with it. Two high risk pulmonary embolism patients did not receive such therapy, as we could not diagnose them when they presented to us. They were treated in line of ACS initially. All the patients were discharged on Warfarin after few days of hospital stay. RESULTS The age range was between 31-68years. There were 8 male and 3 female patients. Among eleven patients three were diagnosed as high risk pulmonary embolism, eight were intermediate risk. About the predisposing factors two have facture bone; cancer in one, recent surgery in one, remaining three patient don t have any predisposing factor. Nine of these patients presented to the ER. Nine cases were referred cases from other hospital with the diagnosis of ACS, only one patient 65 CONCLUSION PE is a common cardiovascular emergency. Diagnosis of PE is tricky because of non-specific sign and symptom. Shortness of breath and chest discomfort is the common symptoms. Though ECG and chest x-ray has minimal role in the diagnosis but they can help us to make us suspicious about the diagnosis. ECHO can provide important information in the diagnosis of PE. Suspicion is the most important part to come to the diagnosis of PE.

79 ABSTRACT Prolonging the intubation period, inotropic support and preload reduction improves outcome of pericardiectomy in cases of constrictive pericarditis Sajal Upreti, Uma Gurung, Purnima Rai, Subash Pant, Anil Acharya, Raamesh Koirala. *Department of Cardiovascular Surgery, Shahid Gangalal National Heart Centre BACKGROUND Pericardiectomy is the only accepted curative treatment for improving cardiac haemodynamics in chronic constrictive pericarditis (CCP) but mortality is uniformly high, reported at up to15 %. METHOD The database from all patients undergoing Pericardiectomy by a single surgeon in our hospital from January 2006 till July 2010 was reviewed to analyze the early outcomes. RESULTS The total number of patients was 40 among them 25 were male and 15 female (M:F=1.6:1). Mean age was ±12.79 (range 8-63 years). The duration of illness ranged between 3 to 13 months. The most common presenting symptoms were dyspnoea, abdominal discomfort and abdominal distension. Post operative ventilation period was 31±12 hours (18-96 hrs). Mean duration of post operative inotropes use was 40.6 hours (24 to 100 hours). Preload reduction was done with glycerine trinitrate infusion and was started during operation and continued for the mean period of 30 hours (24 to 40 hours). The mean ICU stay was 3.23±2.25 days (2-13 days) and total postoperative hospital stay was 10.36±8.24 days (4-47 days). 3% had minor complication which included superficial wound infection and pleural effusion. One patient had delayed sternal closure.there were 2 mortalities (5%) and among them one had effusive constrictive pericarditis. CONCLUSION From this study we can conclude that pericardiectomy can safely be performed without the use of CPB, and outcomes in respect of early mortality can be improved by prolonging the intubation period, inotropic support and preload reduction. 66

80 ABSTRACT Primary PCI in young patients in SGNHC, its prevalence and prognosis Rajbhandari R, Prajapati D, Adhikari CM, Limbu YR *Shahid Gangalal National Heart centre, Bansbari kathmandu OBJECTIVE We sought to determine in-hospital and intermediate-term outcomes of primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) in young adults. MATERIAL AND METHODS We reviewed 78 consecutive patients treated with primary angioplasty for acute MI;the results of primary procedure among young (45 years and below) and relatively older( above 45years) patients were compared. Clinical characteristics, in-hospital and intermediate-term outcomes of primary PCI were analyzed. RESULTS Compared with older patients, the young patients had significantly lower in-hospital mortality p<0.001; young group had lower unsuccessful procedure rates of primary PCI for STEMI. These results suggest that young adults who underwent primary PCI have favorable in-hospital outcomes. CONCLUSION Primary PCI for young adults with STEMI is safer, more feasible and effective than for a relatively older population. 67

81 ABSTRACT In Vitro Cardiogenesis can be initiated in Human CD34+ Cells 1 Sarma PV, 2 Subramanyam G * 1 Department of Biotechnology, Sri Venkateswara Institute of Medical Sciences, Tirupati, India * 2 Department of Cardiology, College of Medical Sciences, Bharatpur, Nepal Key words: Cardiogenesis, Stem cell therapy, Myocardial infarction BACKGROUND The extensive damage that occurs in the cardiac tissue after myocardial infarct is the major concern in post infarct management. It is known that the transplantation of autologous stem cells/ fetal cardiomyocytes in the heart scar tissue developed due to infarct limits the scar expansion and prevents post infarct heart failures. The adult stem cells mobilized by administration of G-CSF result in homing of stem cells into the damaged myocardium. This is because of the fact that stem cells have the ability to proliferate and capacity to generate into multiple cell lineages. However the homing process due to the transplantation of autologous stem cells is time consuming. METHOD This study was conducted in Tirupati, India in the department of Cardiology with the collaboration of Department of Biotechnology. A healthy donor was selected as per the guidelines given by the institutional ethical committee and Helsinki declaration. The donor was given G-CSF 5 microg/ kg/day and stem cells were harvested from the peripheral blood using Fresenius ASTec204 cell separator. The PBSC were then evaluated by immunohistochemical staining using anti-human CD34 monoclonal antibodies. The cells were then cultured in DMEM with 10% FCS for 17 weeks and in vitro cardiogenesis was initiated by adding 4 microm/l 5'Azacytidine. RESULTS In vitro cardiogenesis was initiated in pure CD34+ cells with 5' Azacytidine. The cells showed spontaneous beating after 24 hours of treatment and after 5 weeks, the cells connected with the adjoining cells by a myotube. In these cells, expression of myosin light chain (MLC2v) gene and GATA-4 transcription factor validated the development of cardiomyocytes. CONCLUSION Our method of in vitro cardiogenesis from autologous stem cells could be the future method of developing cardiomyocytes which can be further used to limit the size of infarcted myocardium and this modality would be less-time consuming. 68

82 ABSTRACT "An evaluation study of Intensive Care and Coronary Care Nursing Training" Jamuna Sayami *Institute of Medicine, TUTH, Maharajganj, Kathmandu INTRODUCTION Intensive Care Unit and Coronary Care Unit (ICU/ CCU) Nursing Training has been started in Tribhuvan University Teaching Hospital (TUTH) since 1999 for the fulfillment of shortage of trained nursing staff to run specialty services like Intensive care and coronary care. More than 100 staff nurses were trained till date. OBJECTIVE OF THE STUDY 1. To assess knowledge, attitude and skill of trained nurses. 2. To evaluate appropriateness of staffing for efficient functioning of ICU/CCU. 3. To assure nurse's performance of advanced skills like CPR, DC shock, Intubation / Extubation and ECG monitoring etc. 4. To identify job satisfaction and refresher training needs. 5. To suggest areas for policy for program improvement. METHODOLOGY A descriptive case study with 100 samples of trained ICU/CCU nurses from all hospital were selected purposively for quantitative and qualitative data. Study tools were self-administered questionnaire, Knowledge test checklist, Skill test checklist and Health facility assessment checklist. RESULTS Sixty-one nurses responded from thirteen hospitals. The personal characteristics showed median age of nurses was 30 years. 62% Certificate level and 27% Bachelor Nursing graduates, 85.2% married, only 5% sister incharges. 54% are currently working in ICU/CCU. Skill Test- Ten scales of common procedures were used for performance observation in ICU/ CCU. The majority of nurses scored more than 80%. Knowledge test was done by forty items checklist with true and false responses, which revealed 49 nurses scored 60-80% and 11 scored less than 60%. Result of physical facility showed most hospitals have emergency cart and emergency medicines with required equipments but none had preparation room, Isolation room, alarm system, central line of O2 and suction, central monitor and ABG machine except in TUTH. Majority of nurse were moderately satisfied with ICU/CCU nursing Training. CONCLUSION ICU/CCU nursing training helps to improve quality of nursing care and should be further strengthen. 69

83 ABSTRACT Outcome Of Minimally Invasive Approach For Aortic Valve Replacement Jyotindra Sharma, Krishna Bhandari, Rabindra Timala, Apurba Sharma, Jeju Pokharel, Murari Raj Uprety. *Department of Cardiac surgery and Anaesthesiology, SGNHG, Bansbari, Kathmandu INTRODUCTION Minimally invasive cardiac surgery through upper mini-sternotomy has clear benefits compared with standard sternotomy. These benefits include less surgical trauma, less bleeding, decreased pain, reduced risk of wound infection, shorter hospital stay and faster rehabilitation. This retrospective study compares post-operative outcomes of aortic valve replacement using a minimally invasive approach opposite to conventional surgery. METHODS Between October 2009 to September 2010, 25 patients underwent elective isolated Aortic Valve Replacement (AVR) in unit III of Department of cardiovascular surgery, seven of which were done using a J mini-sternotomy with a 7-8cm skin incision. Average age of the patients in conventional group (Group A) was 35.6 ±21.5years while it was 27.1±9.4 years in minimally invasive group (Group B). Outcome variable analyzed and compared were cross-clamp and cardiopulmonary by-pass time, mortality, IUC stay, post-operative ventilation time, Peri-operative major complications and total post operative drainage. RESULTS There were no statistical differences in both groups in terms of by-pass and cross-clamp times. There is a trend towards a lower postoperative ventilation time, ICU stay and post operative drainage in the minimally invasive group. There was one re-exploration, one sternal wound infection and one mortality in conventional group compared to none in minimally invasive group. CONCLUSION Minimally invasive approach for aortic valve replacement via partial sternotomy is safe, reliable and practical. 70

84 ABSTRACT Community Based Screening and Intervention for Coronary Risk Factors and Chronic Kidney Disease in Eastern Nepal Sharma S K 1, Gautam S 1, Gimire M 1, Ghimire A 2, Pandey N 1, Bhattarai M 1, Shrestha H 1, Barakoti M 1, Koirala P 1, Thapa S 1, Parikh S 1, Karki P 1 * 1 Department of Internal Medicine, * 2 Department of Community Medicine and Public Health, B P Koirala Institute of Health Sciences, Dharan, Nepal INTRODUCTION We conducted first community-based screening and intervention study in eastern Nepal with the aim to create awareness, detect and manage risk factors for chronic kidney disease, diabetes, hypertension and cardiovascular disease (CVD), that ultimately expected to prevent CVD deaths and prevent chronic kidney disease (CKD) progression. METHODS A collaborating network among primary health center or equivalent, district hospital and tertiary care center along with community-based volunteer program was created to educate, screen and intervene for hypertension, diabetes, cardiovascular risk factors and CKD. The main strategies of intervention were public and heath professional education, intersectoral collaboration, community participation and organization and early detection and management of CVD and CVD risk factors. General health status and lifestyle habit, physical examination and blood pressure were assessed. The urine sample was tested by Multistix and for albumin/creatinine ratio (selected cases). Serum creatinine, fasting glucose and lipid profile were estimated. A cardiovascular risk factor score, 0 to 6, was determined. A mechanism was developed to follow-up screened positive persons in primary or equivalent health centre. Referrals were made to tertiary care centre as needed. The subjects were closely monitored by community volunteers to pursue follow-up and adherence to prescribed 71 treatment. Achievement of blood pressure and glycemic control, ceasation of smoking (subjective) and reduction of proteinuria was assessed. RESULTS A total of 25,000 people from 4 districts of Eastern Nepal were evaluated. Mean age of screened population was 39.5years.History of stroke, heart attack or angina and smoking were elicited in 0.56%, 1.21% and 0.56% and 23.5%. 49% had sedentary life style. Hypertension, obesity, diabetes were found in 22%, 5.3% and 8.4% of the screened population, respectively. 40% of hypertensive and 48% of diabetics patients were newly detected during the screening. Two or more cardiovascular risk factors were present in 29.6% of the screened population subjects positive at screening entered an intervention program by combining lifestyle modifications and pharmacological management patients reached 6 to 30 month follow-up. Glycemic (HbA1c <7%) and blood pressure control (<140/90 mmhg) was achieved in 63% and 73%, respectively. Regression or stabilization of proteinuria was achieved in 51% of patients.. CONCLUSIONS Comprehensive community-based program for early detection and intervention to reduce burden of CKD and CVD is feasible in Nepal, with fewer resources. Networking of health care setup and engaging community helped to adhere follow-up and treatment.

85 ABSTRACT Surgical Experience with Cardiac Myxomas Jyotindra Sharma, Sandip Bhandari, Rabindra Timila, Suman Sherchan, Sidhartha Pradhan, Bijoy Rajbanshi, Anil Acharya, Navin Gautam, Yogeshwor Man Singh, Raamesh Koirala, Bhagawan Koirala, Apurba Sharm, Jeju Pokharel, Murari Raj Uprety *Department of Cardiac surgery and Anaesthesiology, SGNHC, Bansbari, Kathmandu INTRODUCTION Primary cardiac tumours are rare with autopsy incidence of less than 0.1 percent. Myxomas are the most common primary cardiac tumours. We present our experience on surgical treatment of such tumours. METHODS Since 2001, thirty two patients underwent surgical intervention for cardiac myxomas at our centre. Mean age was 48.7 ± 17.2 years. Majority, 25 patients were female. Twenty eight patients had left atrial myxoma and remaining 4 patients had right atrial myxoma. Surgical excision of tumour was done under cardiopulmonary by-pass and cardioplegic cardiac arrest. RESULT Complete excision was possible in all cases. Biatrial approach was used for left sided myxomas while right sided myxomas were excised via right atrial approach only. The resulting defect in interatrial septum was repaired with either pericardial patch or direct closure. There was no operative mortality. All patients were symptoms free and free from recurrence on follow-up echocardiography. CONCLUSION Surgical excision of cardiac myxomas is possible with excellent surgical outcome. 72

86 ABSTRACT Initial Experience of Transesophageal Echocardiography in NAMS Bir Hospital Shah R. K *Department of Cardiology, NAMS, Bir Hospital, Kathmandu, Nepal Key words : Transesophageal echocardiography, Transthoracic echocardiography INTRODUCTION In 1976, Frazin and colleagues first attached a single crystal M-mode ultrasound transducer to the tip of a cable for esophageal imaging. Since that time, improvements in ultrasound technology coupled with miniaturization of transducers and the development of soft flexible tubing have led to a virtual exponential growth in the use of transesophageal echocardiography. MATERIALS AND METHODS A retrospective study that was conduncted in the department of cardiology of NAMS, Bir Hospital, Kathmandu from April 2008 to March All patients with proper indications were subjected to transesophageal echocardiography. Instrument used was Toshiba xario (PST 50 AT, 5 MHZ). The procedure was explained to the patient, and an informed consent was obtained from the subjects. All data were analyzed by using statistical package for social science (SPSS) version 10 for windows. A careful history was obtained before performing the transesophageal echocardiographic examination. In addition to a thorough cardiovascular history, specific questions was asked regarding past esophageal injury or surgery, swallowing difficulty, gastrointestinal bleeding, medications (e.g., aspirin), and allergies to medications (e.g. lidocaine).to minimize the risk of aspiration during the procedure the patient had nothing by mouth for at least four hours and preferably six to eight hours before the procedure. RESULTS A total of 51 patients were included in the study. Among the 51 patients 29 (56.8%) were female and 22 (43.2%) were male. Mean age was 38+/ (range years). Atrial septal defect were 25 (49.0%), Normal were 11 (21.6%), Left atrial clot were 4 (7.8%), Constrictive Pericarditis were 4 (7.8%), Right atrial Myxoma were 3 (5.9%), Prosthetic valve were 2 (3.9%), Pericardial cyst was 1 (2.0%), and Vegetation was seen in 1 case (2%). 73

87 Initial Experience of Transesophageal Echocardiography in NAMS Bir Hospital In reported series, the incidence of major and minor complications is 2% to 3% with most being minor complications. Major complications (death, esophageal perforation, significant arrhythmias, congestive heat failure, and aspiration) occur with a frequency of 0.3%, with a reported mortality of less than 0.01%. Reported minor complications include transient hypotension, hypertension (particularly with agitation), hypoxia, and arrhythmias (such as sustained ventricular tachycardia, nonsustained ventricular tachycardia, and transient atrioventricular block). Methemoglobinemia has been rarely reported due to the anesthetic spray and should be considered if cyanosis occurs. In this study most common problems were nausea and vomiting in 22 cases (43.1%) during procedure. Sore throat was in 3 cases(5.8%) after the procedure. Ventricular premature contractions were seen in I case(1.9%). The improved resolution and anatomic detail provided by transesophageal echocardiography, as compared with transthoracic echocardiography is what makes it such a powerful diagnostic tool. However, this can also lead to misinterpretation of normal structures. CONCLUSION Transesophageal echocardiography is a safe outpatient procedure. Viscous two percent lidocaine topical anesthesia was adequate for the procedure. Common indication for Transesophageal echocardiography was to confirm Atrial septal defect and Left atrial clot. Complications of Transesophageal echocardiography was very few. Misinterpretation of normal structures are best minimized by the experience of the operator. 74

88 ABSTRACT Radiofrequency Catheter Ablation of Supraventricular Trachycardias In Nepal Man Bahadur KC, Sujeeb Rajbhandari, Roshan Raut, Murari INTRODUCTION Shahid Gangalal National Heart Centre (SGN- HC) is the first and the only one facility providing electrophysiological studies (EPS) and radiofrequency catheter ablation (RFCA) for supraventricular tachycardia (SVT) in Nepal. The first RFCA for SVT in Nepal was performed on 13th October 2003 with portable EP lab (EP Tracer Johnson and Johnson). To date, a total of 614 RFCA procedures for SVT have been performed in SGNHC. The retrospective analysis of this patients population has provided an opportunity to narrate our initial experience regarding baseline characteristics, EP findings, immediate and follow up outcomes and complications. METHODS AND SUBJECTS This study includes 614 subjects with SVT who underwent RFCA in SGNHC in between 13th October, 2003 and 31st August, The patients baseline characteristics, EP findings, immediate outcome, follow up outcome and complications were obtained from the hospital registry. Among these 614 subjects, 215 were male (35%) and 399 were female (65%). The age range was years. The follow up period was from a maximum of 105 months to minimum of one month. Before the procedure, the AV nodal blocking agents such as beta-blockers and verapamil were discontinued for at least five half lives and amiodarone for two weeks. The procedures were performed in Philips 5000H cath lab. Using EP Tracer (Johnson and Johnson) EP lab system. Diagnostic catheters were placed through the right and left femoral veins into RA, Bundle of HIS region and RV apex. A coronary sinus catheter was inserted through the internal jugular vein. Left heart catheterization was performed through femoral artery route or through the tans-septal puncture mode via the femoral vein. After the programmed stimulation and electrophysiological maneuvre, the reentrant loop of SVT was identified and radiofrequency energy was applied (using Stockhart Ablator) at the relevant anatomic area. All the patients were discharged at very next day and kept on aspirin and/and or clopidogrel for 6 weeks. RESULTS Among 614 subjects, 271 patients (44.1%) had atrioventricular nodal reentrant tachycardia (AVNRT) with female preponderance (72%). 258 patients, out of 271 were typical AVNRT (75.2%) and 13 were atypical AVNRT (4.8%). All 271 patients had undergone RFCA successfully without any relapse till date. 320 patients (52.1%) had accessory pathways, male 174 and female patients had typical Atrial flutter, and all of them 75

89 Radiofrequency Catheter Ablation of Supraventracular Trachycardias in Nepal had undergone RFCA successfully, without relapse in follow up period. Among 320 patients with accessory pathways, 219 (68%) patients manifested W-P-W, while 101 (32%) had concealed accessory pathways. Left sided pathways were found in 203 patients (63.4%), Right sided pathways were found in 47 patients (14.7%), and septal pathways were found in 70 patients (21.9%). Almost 64% of the left sided pathways were manifested as W-P-W Syndrome, and 87% of right sided pathways were manifested as W-P-W; left lateral accessory pathways was most common pathways, i.e. 52% of total accessory pathways. 2 patients had Mahaim pathway and 2 had coronary sunus diverticulum. 10 patients had multiple pathways. The male female ratio of manifest W- P-W was 52% to 48%, where as the male female ratio of concealed AP was 60%-40%. RFCA was not attempted in 6 patients as they had antero-septal and or parahisian pathways and patients did not give consent due to the risk of heart block. RFCA was not successful in 13 patients due to technical regions. Among these 614 successful ablations, tachycardia recurred in 5 cases (around 1%); all were accessory pathways (one mid-septal AP and 4 right sided APs). 12 patients had reappearance of delta waves without recurrence of tachycardia. 4 patients with typical atrial flutter had successful ablation. Likewise one had successful ablations for permanent junctional reciprocating tachycardia (PJRT) and one had successful ablation for long right atrial tachycardia. In this series, severe vaso-vagal syncope occurred in one elderly woman (needed mechanical ventilation), major hematoma in one (needed surgical intervention), and minor hematoma in 4 and reversible limb ischemia in one patient and one 2:1 AV block. There was no event of death, cardiac tamponade, stroke or malignant arrhythmia requiring DC shock. CONCLUSION In our series, the success rate of RFCA in AVNRT and left accessory pathways is very high (>99%), where as the success rate in right sided and septal pathways is around 90%. Overall, EPS and RFCA procedures can be safely done in our centre with immediate and long term high success rate and minimal complications. 76

90 ABSTRACT Outcome of Coronary Bypass Surgery in Private set up in Nepal Prakash Poudel, Nabin Gautam, Jeju Pokharel, Murari Upreti, Bhagawan Koirala *Norvic International Hospital, Kathmandu BACKGROUND Cardiac Surgery is an emerging speciality in Nepal. First Open Heart Surgery in Private set up was performed by our team in May Ever since this program has been a complementary one to the already existing strong public sector programs. OBJECTIVES To review the outcome of Coronary Artery Bypass in a private hospital set up. MATERIALS AND METHODS This is a retrospective analysis of the patients operated in Norvic International Hospital over the period of the last seven years ( ). The data were collected from hospital records. RESULTS Total of 176 cardiovascular surgeries were performed by our team in this hospital of which 97 patients underwent Coronary Artery Bypass Grafting (CABG). Among the patients who underwent CABG 40% had double vessel bypass,38% had triple vessel bypass, 4% had four vessel bypass and one had combined CABG and Aortic Valve Replacement. Sixty seven patients had onpump bypass and the remaining off pump. There were two deaths in the series in the early years but none in the last 50 cases. Total of four patient required re-exploration for bleeding and one required prolonged ventilation. CONCLUSION Cardiac surgery can safely be performed in a private setting of Nepal. 77

91 ABSTRACT Fast-Track Cardiac Anaesthesia: A Retrospective Review of 6 months Period at SGNHC JN Pokharel, MR Upreti, A Sharma, BD Sharma Regmi BACKGROUND With the evolution of anesthesia and surgical procedures, fast track cardiac anaesthesia (FTCA) has gained an increased interest, mainly based on the possibility of reducing health costs seemingly without compromising patient care and has been implemented at SGNHC. OBJECTIVE The purpose of this study is to evaluate the status of FTCA after open heart procedures. METHODS After standard anaesthesia and surgical technique, we retrospectively reviewed the duration of mechanical ventilation, length of ICU stay, reintubation, and incidence of in hospital mortality in 277 adult patients undergoing open heart surgery during 6 months period at SGNHC. RESULTS The median time of the extubation was 6 hours, median days of the ICU stay was 3 days. Five cases were reintubated because of the respiratory failure which is about 1.8% out of 277 cases. Out of 277 eight patients had to be re-explored for the postoperative bleeding and 7 patients (2.5%) died of sepsis and low cardiac output syndrome. 78

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