The extent to which cytochrome P450 (CYP) 2C19 genotype influences the effectiveness of clopidogrel remains uncertain due to considerable heterogeneity between studies. We used the polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) method for genotyping loss of function (LOF) allele, CYP2C19*2 and gain of function (GOF) allele, CYP2C19*17 in 163 patients undergoing PCI and 165 healthy volunteers from an ethnically distinctive Bangladeshi population. Thirty-eight patients took prasugrel and 125 patients took clopidogrel among whom 30 patients had their clopidogrel active metabolites (CAM) determined by LC-MS/MS 1-1.5 h after clopidogrel intake. All patients who underwent PCI had their P2Y12 per cent inhibition (PRI) measured by VerifyNow System. The impact of different genotypes on CAM and PRI were also determined. We did not find significant variation of CYP2C19*2 (P > 0.05) and CYP2C9*17 (P > 0.05) alleles among healthy volunteers and patients. CAM concentration as well as PRI by clopidogrel varied significantly (P < 0.05) based on genotypic variation of CYP2C19*2 and CYP2C19*17 individually. Such influence was not observed in case of prasugrel. Genotypic variation did not impact PRI but as a whole PRI by prasugrel was better than that of clopidogrel (P < 0.05). Due to presence of both of alleles the effect on PRI by clopidogrel could not be predicted, effectively indicating possible involvement of other factors. Genotype guided clopidogrel dose adjustment would be beneficial and therefore we propose mandatory genotyping before clopidogrel dosing. Prasugrel proved to be less affected by genotypic variability, but due to lack of sufficient long-term toxicity data, caution would be adopted before substituting clopidogrel.

Aims: Radial approach is gaining the momentum as a default technique for coronary procedures. Limited trails are available for post coronary artery bypass graft (CABG) patients to compare the merits of femoral & radial access. Methods: It is a single-center study conducted in between January, 2013 to December, 2015. During this study period, post CABG patients were blindly assigned to its five high volume operators. Coronary angiography & intervention procedures were performed by left radial or femoral approach as per assigned operator's choice. Contrast volume was the primary endpoint whereas the procedure & fluoroscopy time, procedural success, access site major bleeding, pre discharge major adverse cardiac event (MACE) were the secondary endpoint both for coronary angiogram (CAG) & percutaneous coronary intervention (PCI). Results: Total 380 post CABG patients were included in this study period. Radial access (n=155) was lower than femoral access (n=225). Compared with femoral access, diagnostic CAG required relatively lower contrast volume though statistically not significant via radial access (70±34 vs. 72±40 ml, p=0.267). Procedure time (25.2±10.7 vs. 26.9±6.8 min, p=0.735), fluoroscopy time (10.7±5.5 vs. 9.5±4.7 min, p=0.424) were almost similar in both access for CAG. Other secondary clinical endpoints were similar among both groups. Interestingly, adhoc PCI was more frequent in radial group (n=54 out of 155, 34.8%) than in femoral group (n=44 out of 225, 19.6%) with p=0.01. Contrast volume in between two groups was pretty similar with p=0.226. The incidence of other secondary endpoints was also not statistically significant. Conclusion: Coronary angiography for post CABG patients through left radial approach seems to be effective, non-inferior in terms of contrast volume, procedure & fluoroscopy time & other clinical end points comparing to femoral access. Anwer Khan Modern Medical College Journal Vol. 10, No. 1: Jan 2019, P 11-16

Myocardial calcification is a rare and life-threatening condition. It has been associated with a myriad of causes, including ischaemic heart disease, cardiac surgery, rheumatic fever, and myocarditis. However, this entity is less well recognised in the setting of toxic shock syndrome. Published medical literature is scarce with regard to the pathogenesis and clinical implications of this potential association. We chronicle here the case of a patient with myocardial calcification secondary to toxic shock syndrome from our clinical experience. Furthermore, a systematic literature search of the medical databases PubMed and Google Scholar was conducted. A total of 17 cases fulfilled the inclusion criteria. The data on patients’ characteristics, epidemiology, clinical features, comorbid conditions, diagnosis, clinical course and outcome were collected and analysed. The present review outlines our current understanding of the epidemiology of and risk factors for sepsis-related myocardial calcification, the pathophysiology of this condition and currently available approaches to diagnosis.

Retroperitoneal hematoma may occur as a result of trauma, rupture of arterial aneurysms (aortic or iliac), surgical complications, tumors and anticoagulation therapy. A life threatening retroperitoneal hemorrhage or hematoma is an infrequent complication of anticoagulation treatment. Enoxaparin is a low-molecular-weight heparin (LMWH) with several advantages over unfractionated heparin. Nevertheless, enoxaparin use is not without risk and severe retroperitoneal bleeding may occur following its use with a potentially fatal outcome. We report a case of sixty six years old female patient who develops a fatal retroperitoneal hematoma two days after enoxaparin treatment for acute coronary syndrome. Keywords: Retroperitoneal hematoma; Enoxaparin; Acute coronary syndrome. DOI: 10.3329/cardio.v3i1.6434Cardiovasc. j. 2010; 3(1): 94-97

Objective: To evaluate in-hospital and 1-year outcomes of primary percutaneous coronary intervention (PPCI) in elderly patients with ST-elevation myocardial infarction (STEMI). Methods: All patients aged ≥ 65 years presenting with STEMI and undergoing PPCI at Ibrahim Cardiac Hospital & Research Institute, Bangladesh from January 2015 to August 2017 were consecutively included in the study based on predefined eligibility criteria. Data pertaining to angiographic characteristics, procedural variables, in-hospital and 1-year outcome variables were recorded and analyzed with the help of descriptive statistics and Chi-square Test. Results: The mean age of the patients was 69.2 ± 5.2 (range: 65-85) years with male to female ratio being 4:1. The patients were predominantly diabetic (78%) followed by hypertensive (74%) and dyslipidaemic (70%) smoker (54%). Half of the patients presented with anterior myocardial infarction (MI), 30% had inferior MI, 12% with right ventricular (RV) extension and 8% with inferolateral extension. About one-quarter (24%) had arrhythmia with complete heart block (CHB). The culprit arteries were LAD (50%), followed by RCA (42%) and LCx (8%). Nearly half (46%) had single vessel disease, 34% double and 20% triple vessel disease. Majority (80%) received a single stent and 20% required two stents with mean diameter and length of the stents were 2.9 ± 0.4 mm and 27.3 ± 7.9 mm respectively. Intracoronary eptifibatide was used in 20% cases. In terms of left ventricular ejection fraction (LVEF), 58% and 28% had mild and moderate LV systolic dysfunction respectively. The mean duration of hospital stay was 4.0 ± 1.9 days. About 18% required repeat hospitalization. Overall, 7(14%) patients died (4 during their stay in the hospital due to cardiac cause and 3 during follow up due to non-cardiac causes). At 1 year follow up, in-stent restenosis was seen in 1 case followed by target vessel revascularization (TVR). The Association between age and outcome revealed that advanced age (age ≥ 75 years) was an important predictor of in-hospital and one-year outcome with Relative Risk (RR) of having unfavorable outcome was > 5-fold (95% CI: 1.6-19.5) in patients of advanced age than that in patients of age < 75 years (p = 0.008). Conclusion: Primary PCI is a feasible treatment option for elderly Bangladeshi patients presenting with STEMI with fewer in-hospital and 1-year follow up deaths. Adverse cardiovascular events are even less. Advanced age (age ≥75 years) is an important determinant of adverse cardiovascular events including mortality, probably because of more medical co-morbidities associated with advanced age. Ibrahim Card Med J 2020; 10 (1&2): 18-26