Acute coronary syndrome is a lethal condition. Treatment modality and success mostly depend on time yielded since onset of symptoms. It is known for more than 30 years that delay between symptom onset and treatment of less than 60 min are desirable, but pre hospital delays remain unacceptably long worldwide including Bangladesh. A greater understanding of the contributing factors may help to reduce delays. A number of sociodemographic, clinical, social and proximal factors have been associated with pre hospital delay. The total pre hospital delay period consists of two component: time taken by patients to recognize that their symptoms are serious and to contact medical help (decision time) and the time taken from requesting help to admission where emergency coronary care is available (time to hospital delay). Different factors may affect these two components. In hospital delay also known as door-to-treatment, is defined as time from arriving to hospital to initiation of reperfusion therapy. Regardless of how to shorten in hospital delay, if the pre hospital delay is not reduced, then reperfusion therapy cannot achieve the best results. We set out to discover what factors are specifically associated with three components: decision time, home to hospital delay and First Medical Contact (FMC) to revascularization delay. This review may help the National health management system to identify the factors associated with treatment delay in ACS and thus reduces ACS related morbidity and mortality. University Heart Journal Vol. 15, No. 2, Jul 2019; 79-85

Introduction:The basis of pathophysiologic benefit of revascularization is improving the function of viable myocardium 37 . Early coronary re-canalization helps to survive the viable myocardium and improve global LV function and survival 46 . According to the studies in patients with CAD and LV dysfunction, the disease outcome can be improved with surgical revascularization (CABG) or PCI 37 . PCI in patients with preserved LV function and optimal medical therapy doesn't reduce the cardiac death and MI, but it decreases the need for other procedure and the risk of angina. Its effect on LV systolic or diastolic function is not clear 31 . PCI has been used increasingly for revascularization in ischemic heart disease (IHD) patients. In most of the studies, the primary PCI, criterion such as ejection fraction (EF), diastolic function and the wall motion or chamber sizes has been investigated. But result of previous studies in related area, about elective PCI, has shown unequal viewpoints 1,6,13,27,30,32,39,41 . Intervals between MI and PCI, basic left ventricular ejection fraction (LVEF) before PCI and global condition of the patients affect the result of PCI. Angina occurs when there is regional myocardial ischemia caused by inadequate coronary perfusion and is usually but not always induced by A Study of Changes in Various Echocardiographic

not available University Heart Journal Vol. 16, No. 1, Jan 2020; 11-15

Ventricular septal rupture (VSR) after acute myocardial infarction with the consequence of hemodynamic unstability is a rare complication and it's an medical emergency. Mortality of these group patients is higher than 90% to 95% without a rapid diagnosis and correction by surgical intervention.Spontaneous closure of VSR is extremely rare. We report the case of a patient with acute myocardial infarction with ventricular septal rupture (VSR) with cardiogenic shock that was diagnosed in our modern coronary care unit by the bed side portable echocardiographic machine (vivid).The incidence of ventricular septal rupture (VSR) after acute myocardial infarction is extremely rare in this reperfusion era.This condition is associated with a high mortality rate, even after the cardiac surgery . Our case emphasizes the risk factors and evolution of this condition.A 36 years old young hypertensive young man was admitted on 8 th August,2014 through the emergency department of university cardiac centre for central chest pain ,dyspnea, nausea and bilateral shoulder pain for the last last 7-8 days. He consulted with his family physician for the same complaints and later he was referred to get admission in our hospital. The patient's condition was detoriating gradually. Physical examination revealed a regular pulse of 110 beats/min. The blood pressure was 100/70 mmHg and there was a systolic murmur best heard at the apex, radiating to the axilla. . Pulmonary rales were present and there was no peripheral edema, hepatomegaly and raised JVP.The 12-lead electrocardiogram Figure 1) showed sinus rhythm at 125 beats/ min, low voltage QRS complex voltage in the limb leads, q waves in II,III, AvF and a 4 mm ST elevation in the anterior leads (V 2-4 ).Serum troponin T level at admission was 1.75 ng/ml, CK-MB 28 , Serun creatinine 1.25, Serum electrolytes are within normal limit.He was managed as a case of acute antero-septal MI with old inferior MI and on the following day after his admission he developed cardiogenic shock , examination reveals pulse was 115 beats/min and blood pressure was 80/40 mm of Hg.Then we put the patient under ionotrophic support ,transthoracic echocardiography was done and (figure 2,3 & 4) revealed a small rupture of the apical ventricular septum (figure 2) causing a VSR with left-to-right shunt (figure 3) and Doppler study showed the pressure gradient

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not available University Heart Journal Vol. 16, No. 1, Jan 2020; 40-42

not available University Heart Journal Vol. 17, No. 2, Jul 2021; 86-90

Like many other developing countries rheumatic heart disease still poses a great threat to the health system of this country due to its devastating outcome in inappropriately treated cases. PTMC remains a prime treatment option in suitable cases of rheumatic mitral stenosis. But there are controversies and discrepancies in the conventional 2-D echo assessment for proper selection of patients for PTMC. With the advent of newer technologies like 3-D echo with newer options, better assessments are naturally expected. This 3-D echo system raised the hope to fill the shortcomings of 2-D Wilkins’ score. To facilitate this 3-D echo with its scoring system it has to be testified against an established, widely accepted and well-understood existing scoring system that has its limitations. Thus it creates a fertile ground whereupon many studies are being done as it is chosen here. In this study, considering all ethical issues, data were collected from 50 mitral stenosis patients who were scored by means of 2-D Wilkins’ and RT3DE scoring systems prior to PTMC and reassessed echocardiographically to define post PTMC outcome and then from this result to compare the two scoring systems as predictors of outcome of PTMC. This study showed a clear female preponderance (78%) of mitral stenosis patients most of whom belonged to the age group 31-40 years. According to Wilkins’ score all are in the ‘mild’ or ‘moderate’ group but RT3DE scored 24% as severe. Both the 2-D mild and moderate groups had good number of suboptimal outcomes (34% and 24% respectively) although the moderate group had comparatively more optimal outcomes (76% in comparison to 66%) than the mild group (although the difference is not statistically significant), that is, the 2-D score is less consistent. On the other hand the RT3DE score showed a gradual fall of optimal outcome in an ascending order of the score from mild to severe and the differences in outcomes among different groups was statistically significant. This showed a clear superiority of the 3-D scoring system over the 2- D in terms of accuracy and consistency. In the 3-D ‘severe’ group percentage of suboptimal outcome was very high(91.7%). This is the group of patients that were not correctly detected by 2-D echo and as a result the outcome assessment was far from accurate. Due to the higher accuracy and consistency 3-D echo is likely to be more reproducible than the 2-D, 3-D echocardiography was more accurate and consistent than 2-D echocardiography in assessing outcome of PTMC. So, the RT3DE scoring system can be a good supplement to the existing 2-D scoring systemUniversity Heart Journal Vol. 9, No. 2, July 2013; 74-79