IntroductionDespite the established evidence on benefits of controlling raised blood pressure and development of several guidelines on detection and management of hypertension, people often have untreated or uncontrolled hypertension. In this context, we undertook this study to identify the barriers existing in hypertension treatment and control in the municipalities of Kathmandu district in Nepal.MethodsThis was a community based, cross-sectional mixed method study conducted in the municipalities of Kathmandu district in Nepal between January and July 2015. Among 587 randomly selected participants, the aware hypertensive participants were further assessed for the treatment and control of hypertension. For qualitative component, 20 participants having uncontrolled hypertension took part in two focused group discussions and two cardiac physicians participated in in-depth interviews.ResultsOut of 587 participants screened, 191 (32.5%) were identified as hypertensive. Among 191 hypertensive participants, 118 (61.8%) were aware of their problem. Of the 118 aware hypertensive participants, 93 (78.8%) were taking medicines, and among those treated, 46 (49.6%) had controlled hypertension. Proportions of participants taking anti-hypertensive medications varied significantly with age groups, ethnicity, occupation and income. Hypertension control was significantly associated with use of combination therapy, adherence to medication, follow-up care, counseling by health-care providers, and waiting time in hospital. Being worried that the medicine needs to be taken lifelong, perceived side effects of drugs, non-adherence to medication, lost to follow-up, inadequate counseling from physician, and lack of national guidelines for hypertension treatment were the most commonly cited barriers for treatment and control of hypertension in qualitative component of the research.ConclusionLarge proportion of the hypertensive population has the untreated and the uncontrolled hypertension. Efforts to dispel and dismantle the myths and barriers related to hypertension treatment and control are warranted to reduce the consequences of uncontrolled hypertension.

Background and Aims: Acute coronary syndrome (ACS) refers to a group of clinical symptoms consistent with new onset or worsening ischemic symptoms. ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI) and unstable angina (UA) are the three types of ACS. The objectives were to study the risk factors prevalence, angiographic distribution and severity of coronary artery stenosis in ACS among patients admitted in Cardiology Department of Manmohan Cardiothoracic Vascular and Transplant Center (MCVTC). Methods: This is a restrospective study of 419 ACS patients admitted and treated in MCVTC from November 2017 to October 2018. Patients were divided into STEMI, NSTEMI and UA then analyzed for various risk factors, angiographic patterns and severity of coronary artery disease. Results: Mean age of presentation was 59.3Å}12.8 years. Majority were male 317(75.7%). Most patients had STEMI 252 (60.1%) followed by NSTEMI 98 (23.4%) and UA 69 (16.5 %). Risk factors: smoking was present in 241 (57.5%), hypertension in 212 (50.6%), diabetes in 144 (34.4%), dyslipidemia in 58 (13.8%). Single-vessel disease was present in 34.6 % patients, double- vessel disease was present in 27.44 % patients and triple vessel disease was present in 26.3 % patients, left main disease in 1.4 % patients. Normal coronaries were present in 6.4% patients and minor coronary artery disease in 3.8 % patients. Conclusions: STEMI was the most common presentation. Three quarters of ACS were male patients. Smoking was most prevalent risk factor. Single vessel involvement was the most common CAG finding in all spectrum of ACS. Diabetic patients had more multivessel disease.

Introduction: Coronary Angiogram and Percutaneous Coronary Interventions are commonly performed via the femoral route. Then, transradial coronary catheterization became a popular & default technique due to less vascular access site complications and bleeding as compared to femoral route. Distal puncture of the radial artery through the anatomical snuff box access, however, has recently been shown potential benefit, like comfort to patients and operators, as well as maintenance of blood flow through the superficial palmar arch, in case of radial artery occlusion. Our aim was to evaluate the safety and feasibility of this new approach. Methods: A cross-sectional observational prospective study of patients underwent invasive diagnostic or therapeutic coronary procedures through the distal trans-radial access and traditional radial access. The primary endpoints were to access difficulties and in-hospital access-site related complications. Results: In 2 months, 190 patients underwent coronary procedures, of which 82 (43%) were selected in both distal transradial & traditional radial group. In 2 (2.4%) & 3 (3.6%) cases, distal radial & traditional radial access cannulation was unsuccessful respectively (p > 0.05). The mean age was 57.7 ± 10 & 57.2 ± 10 years in successful distal transradial & traditional radial cases respectively. There were no any major vascular complications in distal transradial group while there were 2 vascular complications in traditional radial group (p > 0.05). Conclusions: Distal transradial access is feasible and safe in selected cases, when performed by experienced operators. Larger case series and randomized trials are required to determine its efficacy in reducing vascular complications when comparing to the traditional technique.

Background and Aims: Percutaneous Coronary Intervention (PCI) is the preferred method of revascularization in Acute ST Elevation Myocardial Infarction (STEMI). Our aim was to study the clinical profile and outcomes of patients who underwent PCI for STEMI at tertiary cardiac centre of Nepal. Methods: It is a retrospective, single centre study, performed at Tribhuvan University, Manmohan Cardiothoracic Vascular and Transplant Centre, Kathmandu, Nepal. All patients who underwent PCI for STEMI from November 2015 to July 2018 were enrolled in this study. All the data were collected from hospital registry and cath lab records. Results: The Study showed that out of 232 patients who presented with STEMI, 74.5% were male with average age of 57.39 years. The mean time of presentation after onset of symptom/s was 17.5 hours. About 66% patients presented in less than 12 hours of symptoms onset, 21% presented at 12-24 hours of symptoms onset and 13% patients presented late. Primary PCI was done in 87% of patients. Almost all patients (98.2%) underwent coronary artery stenting with drug eluting stents. Multivessel PCI during index procedure was done in 7 patients. TIMI III flow following PCI was achieved in 97% cases. Average LVEF at discharge was 44.73%. There were 8 deaths, all after Primary PCI. In-hospital mortality rates for patients presenting with and without cardiogenic shock were 38.46% and 1.59% respectively. The overall mortality rate was 3.98%. Conclusion: This study has reemphasized that PCI is effective in the management of STEMI cases in Nepal with improving mortality rates and decreasing complications. Minimizing the delayed presentation after the onset of symptoms should be one of the prime focuses for effective management of STEMI.

Background and objectives: Cardiovascular disease is a major health problem reaching epidemic proportions. Although Acute Coronary Syndrome (ACS) is an uncommon entity in the young, it constitutes a rising burden in the socioeconomic status of the country because of its impact on the economically productive age group. Early identifi cation and control of the cardiovascular risk factors helps to prevent cases of Myocardial Infarction (MI) in young resulting in reduced health burden. Therefore, we aimed to assess clinical pattern and the prevalence of cardiovascular risk factors in the young and economically productive population of an underdeveloped country to lower the socioeconomic burden. Methods: A total of 60 patients presenting at the cardiology department of Manmohan Cardiothoracic Vascular and Transplant Center were included in our study after fulfi lling the inclusion criteria. ACS was diagnosed by cardiac enzymes, electrocardiography, and echocardiography and coronary intervention was done in the cardiac catheterization room. Patients were followed up at 1 and 3-months and reassessed clinically and by echocardiography. Results: Mean age of presentation was 38.55 + 4.98 (SD) years. Over three-fourth of the patients were male (80%) and nearly three-quarter experienced ST-elevated MI (73%). Smoking was the most prevalent risk factor (67%), followed by dyslipidemia (40%), diabetes (32%), hypertension (30%), and obesity (13%). Most of the patients presented with single-vessel disease (65%), followed by double-vessel disease (18%), triple-vessel disease (12%), left main disease (3%), and minor coronary artery disease (2%). Conclusions: ACS in underdeveloped country is more common in male and single-vessel disease is the most common clinical pattern of ACS and smoking the most prevalent risk factor.

Background and Aims: Although pacemaker implantation has been done regularly in Nepal for the last 20 years, there is no large scale published data of pacemaker implantations. Manmohan Cardiothoracic Vascular and Transplant Centre (MCVTC) have been providing uninterrupted permanent pacemaker implantation services since its inception. This led us an opportunity to report the data regarding permanent pacemaker implantations in MCVTC. Methods: Hospital records of all patients who had undergone PPI at MCVTC between Shrawan 2070 – Ashad 2075/ July 2013- June 2018 (5 years) were searched for and all available data were retrospectively analyzed. Results: A total of 277 cases underwent PPI at MCVTC in 5 years. Out of these 165 (59.5%) were male with male to female ratio of 1.47. The mean age was 65.82±16.10 years with 3 (1.1%) cases of <20 years of age and almost 70% of cases aged >60 years. Dual chamber units were implanted in 49 (17.7%) cases. Only 13 women (11.6%) received dual chamber pacemaker compared with 36 men (21.8%) (P = 0.029). The most common indication for PPI was complete atrioventricular block 165 (59.6%) followed by sick sinus syndrome 65 (23.5%). Hypertension 84 (30.3%) was the most common co morbidity present. Complication occurred in 5.4% of cases with wound infection as commonest complication and single mortality due to postoperative complications post-RV repair. Conclusion: Single chamber pacemaker was the most commonly used pacemaker. Dual chamber pacemaker was more common in younger patients. Complete heart block was the most common indication. Permanent pacemaker insertion was effective and relatively safe procedure in MCVTC with few complications.

Background and Aims: Coronary artery disease (CAD) constitute a major cause of cardiovascular morbidity and mortality worldwide with an enormous burden on healthcare resources. Prevalence and pattern of CAD in patients of rheumatic and non-rhemuatic valvular heart diseases varies widely with limited data on optimal strategies for diagnosis and treatment.Methods: This study includes 97 patients with rheumatic and non-rheumatic valvular heart disease who underwent coronary angiogram (CAG) before cardiac surgery. Patients were divided into two groups based on rheumatic heart disease (RHD) & non-rheumatic disease (Non-RHD) and correlate the patterns of CAD.Results: Out of 97 patients, 22 (22.6%) patients were found to have significant CAD. In patients with non-rheumatic origin CAD was common (15 patients, 68.1%) as compared to rheumatic origin (7 patients, 31. 8%). In rheumatic origin, the prevalence was 7(12.2%) out of 57 patients while in non-rheumatic origin, was 15(37.5%) out of 40 patients. In RHD group, all patients with CAD were found to have single vessel diease (SVD) while, in non-RHD group, 11 patients (73.3%) had SVD, 3 patients (16.7%) had double vessel disease (DVD) and one patient (5.6%) had triple vessel disease (TVD).Conclusions: Prevalence of CAD is higher in patients with non-RHD in comparison to those with RHD. We also found SVD to be the most common pattern of CAD in both rheumatic and non-rheumatic valvular heart disease.

Introduction: Pericardial effusion is one of the common cardiac problems in our part of the world and adds burden to the health and economy of the country, as it is associated with high risk of morbidity and mortality. Our objective of the study was to determine the etiological spectrum of pericardial effusion, their clinical presentations and complications and assessing the usefulness of echocardiographic features of effusion in helping to determine the etiology. Methods: A cross-sectional observational prospective study of 63 patients with diagnosis of pericardial effusion was enrolled in the study. Pericardial effusion was diagnosed by echocardiography and pericardiocentesis was done in the cardiac catheterization room. Patients were followed up 3 monthly for 1 year and reassessed clinically and by echocardiography. Results: Patients presenting with pericardial effusion belonged to the age group of 8 to 88 years. The most common etiology was tuberculosis (36.5%) followed by malignancy (19%) and idiopathic/Viral (12.6%). Among malignancies, carcinoma lung was the most common cause followed by lymphoma. Pericardiocentesis was done in 46 patients (73%) and the approach was subxiphoid. The procedure-related complications were in 4 patients (6.3%) and there was no death as a consequence of the procedure. The total mortality was 12 (19%) with in-hospital death of 6 patients (9.5%). Conclusions: The study showed tuberculosis as the most common cause of pericardial effusion in developing countries like Nepal and as a cause of cardiac tamponade in contrast to the studies from the developed world where malignancy remains the leading cause.