ABSTRACT… Introduction: Atrial fibrillation (AF) and wider QRS duration have long been identified to worsen heart failure and LV dysfunction and increase cardiovascular morbidity and mortality. Therefore, it is necessary to identify those patients of heart failure who are at greater risk for cardiovascular morbidity and mortality so that such subjects may be focused for preventive strategies. An association exists between QRS duration and AF with greater incidences of cardiovascular events in patients of heart failure with LV systolic dysfunction. Sampling technique was non-probability, purposive sampling. Result: The study population consisted of male (72.3%) and female (27.7%). Mean LA diameter was 40.3±6.08 mm and mean LV ejection fraction 31.8±6.6 % in the study population. Ischemic heart disease was the most common cause of LV dysfunction (88.3%) followed by non-ischemic cardiomyopathy (8.75%) and non-Ischemic valvular heart disease (3.5%). The frequency of Narrow QRSd (<120 ms) was 62%, Intermediate QRSd (120-150 ms) was 26.5% and Wide QRSd (>150 ms) was 11.5%. The frequency of atrial fibrillation in study population was 15.75%. The frequency of atrial fibrillation was highest in Wide QRSd group (>150 ms) i.e. (60.9%), followed by Intermediate QRSd group (120-150 ms) i.e. (18.9%) and narrow QRSd group (<120 ms) i.e. (6.04%). Patient with atrial fibrillation were more likely to have poor ejection fraction (P<0.0023) and wider QRS duration (P<0.0001). Frequency of atrial fibrillation was highest in Valvular Cardiomyopathy (non-ischemic valvular heart disease) patients (42.8%) as compared to coronary artery disease group (15.3%) and non-ischemic cardimyopathy group (9.4%). Conclusion: In patients of heart failure with reduced ejection fraction (HFrEF), the frequency of atrial fibrillation increases as QRS duration widens. This group of patients must be focused for AF preventive strategies. Key words:Atrial fibrillation (AF), Left ventricular (LV), QRS duration (QRSd). Article Citation: Mir N, Asghar N, Javed S. Heart failure; co-relation of QRS duration with atrial fibrillation in patients with reduced ejection fraction. Professional Med J 2017;24(6):912-918.

Background Preclinical diastolic dysfunction PDD is a well-known but poorly understood risk factor for clinical heart failure CHF. Preclinical diastolic dysfunction and predictors of progression of PDD to CHF in patients with malignancy has never been studied. Purpose The purpose of our study was to determine the incidence of CHF in cancer patients who have preexisting preclinical diastolic dysfunction, with a particular focus on identifying the risk factors contributing to progression of PDD to CHF. Study design We retrospectively sought all the patients who underwent echocardiography from 2003 to 2008 and were found to have preclinical diastolic dysfunction at our institution. PDD was defined as presence of grade I diastolic dysfunction, LVEF ≥50%, and free of clinical diagnosis of heart failure. Of these, only the patients who had a confirmed histopathological diagnosis of malignancy were included in the study. The end point was incidence of clinical heart failure, HFrEF and HFpEF. Multivariable adjusted Cox proportional hazards regression were performed to study the predictors of CHF. Results Out of 1086 patients with PDD and a histopathological diagnosis of malignancy, 208 patients were diagnosed with new onset CHF during the 10 years follow-up. Incidence of CHF, HFpEF and HFrEF was found to be 32.1 per 1,000 person-year, 13.9 per 1,000 person-year and 2.93 per 1,000 person-year respectively. Patients who developed clinical heart failure were found to have more hypertension, diabetes, myocardial infarction, peripheral vascular disease, pulmonary disease, renal disease, hematological malignancies and metastatic disease when compared to patients who did not develop heart failure. In multivariable adjusted Cox regression analysis, age at index date (HR 1.02, 95% CI 1.01–1.04, p=0.001), diabetes (HR 1.74, 95% CI 1.28–2.35, p<0.001), myocardial infarction (HR 2.19, 95% CI 1.49–3.20, p<0.001), lung disease (HR 1.53, 95% CI 1.14–2.06, p=0.004) and renal disease (HR 2.03, 95% CI 1.45–2.84, p<0.001) were independent predictors of CHF in patients with PDD and malignancy. Among chemotherapy agents, Vincristine, Ifosfamide, transtuzumab and Bortezomib were found to be associated with CHF. Conclusion This is the first study ever to report the incidence of CHF, HFrEF and HFpEF and identify a distinct set of predictors of heart failure in patients with PDD and malignancy. We estimated a much higher incidence of CHF (19%) in our study population, when compared to the general population with malignancy. Our study also depicted a significantly high incidence of HFpEF compared to HFrEF (8.3% vs 1.75%). Our study shows that patients with malignancy are at a significantly higher risk of developing heart failure if they have preexisting diastolic dysfunction. This emphasizes the importance of identifying patients with diastolic dysfunction and a more rigorous cardiovascular surveillance to prevent them from potential heart failure. Acknowledgement/Funding None

Introduction: Traditionally, moist dressings are being in used routinely by surgeons for management of diabetic foot ulcers. Recently, there is an encouraging trend of using VAC dressings in such patients. This study aimed to compare the outcome of VAC with moist dressing for management of diabetic foot ulcer. Study Design: Prospective randomized controlled trial. Setting: Department of Surgery, Al-Bukyriah General Hospital, Al-Bukayriah, Alqaseem KSA. Period: June 2012 to 07 December 2016. Methods and Material: 200 patients with diabetic foot ulcers. The patients were divided in two equal groups containing 100 patients each. In group A, 100 patients received VAC dressing treatment while in group B, 100 patients received wet dressings. Wound size, % reduction in wound size, appearance of granulation tissue and fate of wound were main outcome measured which were noted at start of study and at the end of study (4th week of therapy). Results: In group A, there were 73 (73%) men and 27 (27%) women with a mean age of 54.98+7.68 years and in group B, there were there were 75 (75%) men and 25 (25%) women with a mean age of 55.23+6.98 years. Size of wound before treatment in group A was 14.23± 6.78 cm2 which reduced to 5.11±1.91 cm2 at 4th wee and in group B it was 14.41±5.93 cm2 in the start which reduced to 11.29±3.63 cm2 at 4th week (p<0.05). Mean %reduction in wound size in group A was 63.22±9.19 and 22.92±7.18 in group B (p<0.05). In group A, 43 (43%) wounds healed spontaneously with shrinkage and group B only 2(2%) healed spontaneously (p<0.05). Conclusions: VAC therapy is superior to moist dressing in terms of achieving early granulation tissue, reduction in wound size and spontaneous wound shrinkage.

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Introduction: Atrial fibrillation (AF) and wider QRS duration have long beenidentified to worsen heart failure and LV dysfunction and increase cardiovascular morbidityand mortality. Therefore, it is necessary to identify those patients of heart failure who are atgreater risk for cardiovascular morbidity and mortality so that such subjects may be focusedfor preventive strategies. An association exists between QRS duration and AF with greaterincidences of cardiovascular events in patients of heart failure with LV systolic dysfunction.Study Design: Cross sectional survey. Setting: Department of Cardiology, Punjab Institute ofCardiology Lahore. Period: 16-02-2015 to 15-08-2015. Material and Methods: The objectiveof study was to determine the Frequency of QRS Duration groups and Atrial Fibrillation inPatients with Left Ventricular Dysfunction. Sample size of 400 cases was calculated with 95%confidence level, 4% margin of error and taking expected percentage of atrial fibrillation innarrow QRS group i.e. 20.9% (least among all) in patients with left ventricular dysfunction.Sampling technique was non-probability, purposive sampling. Result: The study populationconsisted of male (72.3%) and female (27.7%). Mean LA diameter was 40.3±6.08 mm andmean LV ejection fraction 31.8±6.6 % in the study population. Ischemic heart disease wasthe most common cause of LV dysfunction (88.3%) followed by non-ischemic cardiomyopathy(8.75%) and non-Ischemic valvular heart disease (3.5%). The frequency of Narrow QRSd (<120ms) was 62%, Intermediate QRSd (120-150 ms) was 26.5% and Wide QRSd (>150 ms) was11.5%. The frequency of atrial fibrillation in study population was 15.75%. The frequency of atrialfibrillation was highest in Wide QRSd group (>150 ms) i.e. (60.9%), followed by IntermediateQRSd group (120-150 ms) i.e. (18.9%) and narrow QRSd group (<120 ms) i.e. (6.04%). Patientwith atrial fibrillation were more likely to have poor ejection fraction (P<0.0023) and wider QRSduration (P<0.0001). Frequency of atrial fibrillation was highest in Valvular Cardiomyopathy(non-ischemic valvular heart disease) patients (42.8%) as compared to coronary artery diseasegroup (15.3%) and non-ischemic cardimyopathy group (9.4%). Conclusion: In patients of heartfailure with reduced ejection fraction (HFrEF), the frequency of atrial fibrillation increases asQRS duration widens. This group of patients must be focused for AF preventive strategies.