ObjectivesPoor adherence is one of the biggest obstacles in therapeutic control of high blood pressure. The objectives of this study were (i) to measure adherence to antihypertensive therapy in a representative sample of the hypertensive Pakistani population and (ii) to investigate the factors associated with adherence in the studied population.Methods and ResultsA cross-sectional study was conducted on a simple random sample of 460 patients at the Aga Khan University Hospital (AKUH) and National Institute of Cardiovascular Diseases, Karachi, from September 2005–May 2006. Adherence was assessed using the Morisky Medication Adherence Scale (MMAS), with scores ranging from 0 (non-adherent) to 4 (adherent). In addition to MMAS, patient self-reports about the number of pills taken over a prescribed period were used to estimate adherence as a percentage. AKU Anxiety and Depression Scale (AKU-ADS) was incorporated to find any association between depression and adherence. At a cut-off value of 80%, 77% of the cases were adherent. Upon univariate analyses, increasing age, better awareness and increasing number of pills prescribed significantly improved adherence, while depression showed no association. Significant associations, upon multivariate analyses, included number of drugs that a patient was taking (P<0.02) and whether he/she was taking medication regularly or only for symptomatic relief (P<0.00001).ConclusionsSimilar to what has been reported worldwide, younger age, poor awareness, and symptomatic treatment adversely affected adherence to antihypertensive medication in our population. In contrast, monotherapy reduced adherence, whereas psychosocial factors such as depression showed no association. These findings may be used to identify the subset of population at risk of low adherence who should be targeted for interventions to achieve better blood pressure control and hence prevent complications.

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Background and Purpose-Limited data exist on the frequency and outcome of carotid artery disease in Pakistan. Such information would help guide the usefulness of screening for the condition in this low-middle income health care setting. Methods-A prospective, descriptive study was conducted among 3 large teaching hospitals in Karachi, Pakistan. Patients referred for carotid Doppler ultrasound examination were included if they had experienced a stroke or TIA within the previous month. The severity and morphology of carotid disease were characterized by trained technicians using standardized criteria. Demographic and risk factor data were collected at baseline, and the outcome of patients was assessed at least 6 months later. Results-A total of 672 patients underwent bilateral carotid Doppler ultrasound (1344 carotid examinations). The findings revealed 0% to 50% stenosis in 526 (78%), 51% to 69% stenosis in 57 (8%), 70% to 99% stenosis in 82 (12%), and total occlusion in 7 patients (1%). Potentially surgically correctable disease, defined as 70% to 99% carotid artery stenosis, was present in only 79 (12%) patients, of whom 47 (60%) were ipsilateral symptomatic, 15 (20%) asymptomatic, and 17 (20%) had status unknown. Outcome information at Ն6 months follow-up was available for 36 of the 47 (76%) surgically correctable and only 4 of these patients (12%) had undergone surgical or radiological intervention (carotid endarterectomy in 3 patients and carotid stenting in 1 patient). Conclusion-The frequency of carotid artery disease of at least moderate severity is very low in patients with recent stroke or TIA and there is low utilization of high-cost, carotid intervention procedures in Pakistan. These data raise questions regarding the applicability and cost-effectiveness of routine carotid ultrasound screening in our country and similar population in Asia.

Recombinant tissue plasminogen activator (rtPA) is the only available therapy for acute ischemic stroke. Current clinical protocols limit its use to a three-hour window from symptom onset. The role of thrombolytic therapy between 91 and 180 minutes after stroke onset remains highly controversial. However, studies have shown that rtPA given within six hours of stroke reduced death or dependency (i.e. more patients alive and independent) at three to six months, and this was statistically significant in favor of treatment. [1][2][3][4] Late presentation continues to be a primary cause of exclusion from thrombolytic therapy ABSTRACT: Introduction: There are no studies from Pakistan that describe stroke presentation rates or factors associated with early or delayed presentation. This is important to know because current clinical protocols limit the use of recombinant tissue plasminogen activator (rtPA), the only available therapy for acute ischemic stroke, to a three-hour window from symptom onset. Methods: All patients aged 14 years or above with acute ischemic stroke of ≤ 48 hours duration were prospectively identified from the Aga Khan University Stroke Data Bank over a 22-month period ending May 2001. Results: 269 ischemic stroke patients presented within 48 hours of stroke onset. 55 out of 269 (21%) presented within first three hours and 110 out of 269 (41%) within first six hours. Unawareness of treatment options (p <0.001) and inappropriate diagnosis and field triage (p=0.005) were associated with delayed presentation. Small vessel occlusion or lacunar stroke in the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) ischemic stroke subtype was associated with delayed presentation (p=0.047) and cardioembolic stroke was associated with earlier presentation (p=0.048). Stroke severity assessed with the National Institutes of Health Stroke Scale at a cut off score of ≥15 was not associated with earlier time to presentation at three hours (p=0.114) but there was some tendency at six hours (p=0.097). Conclusions: The rate of early stroke presentation in a Pakistani tertiary care facility is comparable to certain developed countries. To increase the proportion of patients who can benefit from thrombolytic therapy, programs need to be instituted to increase public awareness of treatment options for stroke and expedited referral by the primary care provider. cardioembolique était associé à une consultation plus précoce (p = 0,048). La sévérité de l'AVC évaluée au moyen du National Institutes of Health Stroke Scale avec un point de coupe de 15 et plus n'était pas associée à une consultation plus précoce dans le groupe qui avait consulté en dedans de 3 heures (p = 0,114), mais on notait une tendance en ce sens dans le groupe qui avait consulté en dedans de 6 heures (p = 0,097). Conclusions : Le taux de consultation précoce chez les patients présentant un AVC aigu dans les hôpitaux de soins tertiaires au Pakistan est comparable à celui de certains pays industrialisés. Il faudra établir des programmes d'information pour q...