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Background Ventricular arrhythmias are prevalent among heart failure with reduced ejection fraction (HFrEF) patients. Rapid rate non‐sustained ventricular tachycardia (RR‐NSVT) and sustained ventricular tachycardia (VT) can be detected on implantable cardioverter‐defibrillator (ICD) interrogation due to discrimination algorithms that differentiate supra‐ventricular from ventricular tachycardia. This study aims to assess the incidence of RR‐NSVT and sustained VT on ICD interrogation and their correlation with HFrEF guideline‐directed medical therapy (GDMT) compliance. Methods DesignCross‐sectional, analytical study. SettingHeart rhythm device clinic, Electrophysiology department, National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan. ParticipantsPatients implanted with dual chamber ICD or cardiac resynchronization therapy defibrillator (CRT‐D), aged 18 years or above with HFrEF. Outcome MeasureCovariates included demographics, comorbidities, medications, GDMT compliance, and cardiac rhythm device parameters. Incidence of RR‐NSVT, sustained VT, and their correlation with HFrEF GDMT compliance was assessed using multivariate logistic regression. Results Study evaluated 139 patients. Men 77.7%. The mean age was 56.4 ± 13.9 years. The mean LV ejection fraction was 26.4% ± 5.5%. 109 (78.4%) were GDMT compliant (94.3% on beta‐blockers, 93.5% on renin‐angiotensin inhibitors, 71.9% on aldosterone antagonists, and 15.8% on SGLT‐2 inhibitors). RR‐NSVT episodes were observed in 54 (38.8%) patients, out of whom 37 had RR‐NSVT despite GDMT compliance, although this correlation was not statistically significant. Twelve (8.6%) patients had sustained VT, which was significantly less common with GDMT compliance. Conclusion More than one‐third of participants had RR‐NSVT episodes despite HFrEF GDMT compliance. These patients also had associated sustained VT episodes, the occurrence of which was significantly less with GDMT compliance. Among heart failure with reduced ejection fraction (HFrEF) patients with ICD implants, over one‐third experienced rapid rate NSVT events despite guideline‐directed medical therapy (GDMT) compliance; however, sustained VT occurrence was significantly reduced with compliance—a study highlighting the protective impact of GDMT against life threatening arrhythmias.

Introduction Femoral venous access is routinely used for radiofrequency catheter ablation (RFA) procedures. Deep vein thrombosis (DVT), which is often sub‐clinical, is uncommon following RFCA. Point‐of‐care ultrasound (POCUS) is a cost‐effective way to diagnose DVT. Identification of DVT incidence, especially if sub‐clinical, can direct change in practice to reduce DVT and lay ground for cost‐effective screening strategies postprocedures. The aim of our study is to determine the incidence of DVT after right‐sided radiofrequency cardiac catheter ablation using POCUS. Methods We conducted a single‐center prospective cross‐sectional study in patients undergoing right‐sided RFCA. Within 24 h postprocedure, the participants underwent compression venous duplex ultrasonography using POCUS to look for evidence of DVT in cannulated limb. The contralateral limb that was not cannulated was scanned as a control. Results A total of 194 patients were scanned post‐right‐sided RFCA procedures. Average age was 43.5 ± 13.2 years and 131 (67.5%) were women. A total of 148 (76.3%) patients underwent AVNRT ablation. Ten (5.2%) patients developed DVT, of which nine had sub‐clinical DVT. Age (>53 years), greater sum of sheaths used (>3) and longer duration of bed rest maintained (up to 4.0 h vs. >4.0 h, p = 0.006) were identified as risk factors. Conclusion Most of the DVTs after right‐sided catheter ablation are sub‐clinical. Routine scanning for DVT after right‐sided catheter ablation as well as reducing number of sheaths and bed rest should be considered. Our research study can be practice changing as it demonstrates that certain patient groups are more liable to develop post‐radiofrequency catheter ablation complications. Moreover, these patients can be effectively screened using point‐of‐care ultrasound (which is easily available in most clinical units) as part of routine predischarge evaluation.

Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is a rare genetic disorder that primarily involves the right ventricle (RV). It is characterized by progressive replacement of RV myocardium by fibrofatty tissues. It commonly presents with ventricular tachycardia (VT) of RV origin and may result in RV failure. The aim of this study is to evaluate the clinical characteristics of adult patients with ARVC/D treated at the Heart Centre, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia. This is a retrospective study of patients with ARVC/D diagnosed and treated at the KFSH&RC Heart Centre in Riyadh. Twenty-two cases with ARVC/D with regular follow-up at our Heart Centre from January 2007 to May 2010 were included in this study. The diagnosis of ARVC/D was made according to the revised International Task Force Criteria. The clinical data were collected from patients' charts and electronic medical records. The majority of patients were males (18; 82%). The diagnosis of ARVC/D was definite in 18 patients (82%), borderline in 2 (9%), and possible in 2 (9%). The mean age at diagnosis was 33.3 years. The follow-up period ranged from 29 to 132 months, with a mean follow-up period of 84 months. Ten patients presented with sustained VT, and 3 were survivors of cardiac arrest. Electrocardiogram abnormalities were present in 16/22 patients (72.7%). Echocardiographic changes meeting major diagnostic criteria were seen in 16 patients (76%). Cardiac magnetic resonance imaging was performed in 11 patients, and showed changes compatible with major diagnostic criteria in 7 patients (64%). Implantable cardioverter defibrillators (ICDs) were implanted in 17 patients; 8 had appropriate ICD shocks and 5 had inappropriate ICD shocks. Antitachycardia pacing was effective in terminating most of the VT/ventricular fibrillation episodes. ARVC/D is a rare but increasingly recognized heart muscle disease seen in Saudi Arabia and other parts of the world. It is associated with a highly nonspecific presentation. VT of RV origin is a common presentation for this disease. Antiarrhythmic medications and ICD implantation are the main management options.

Background. Reduced heart rate variability (HRV) indicates dominance of the sympathetic system and a state of “physiologic stress.” We postulated that, in patients with critical illness, increases in HRV might signal successful resuscitation and improved prognosis. Methods. We carried out a prospective observational study of HRV on all patients referred to the rapid response team (RRT) and correlated with serial vital signs, lactate clearance, ICU admission, and mortality. Results. Ninety-one patients were studied. Significantly higher HRV was observed in patients who achieved physiological stability and did not need ICU admission: ASDNN 19 versus 34.5, p=0.032; rMSSD 13.5 versus 25, p=0.046; mean VLF 9.4 versus 17, p=0.021; mean LF 5.8 versus 12.4, p=0.018; and mean HF 4.7 versus 10.5, p=0.017. ROC curves confirmed the change in very low frequencies at 2 hours as a strong predictor for ICU admission with an AUC of 0.772 (95% CI 0.633, 0.911, p=0.001) and a cutoff value of −0.65 associated with a sensitivity of 78.6% and a specificity of 61%. Conclusions. Reduced HRV, specifically VLF, appears closely related to greater severity of critical illness, identifies unsuccessful resuscitation, and can be used to identify consultations that need early ICU admission.

Background Misconceptions regarding activities after pacemaker implantation can result in restrictions in daily life. This study aims at measuring the correction of misconceptions following an educational intervention utilizing a picture based brochure and personal counseling. Methods One hundred and twenty-eight patients were enrolled in a quasi experimental study on the day after pacemaker implantation. Patients’ perceptions about safety of various daily activities, medical procedures, and usage of appliances, in the presence of pacemaker was assessed using a questionnaire before and ten days after an educational intervention using a pictorial brochure. The number of correct responses before and after the intervention was compared to assess the change in patients’ perception. Results A total of 128 patients were interviewed at baseline, of which 115 followed-up at 10 days. Mean age of patients was 60.31 ± 12.81 years. In total, 76 (59.4%) were male and 61(47.7%) were illiterate. Mean correct responses increased from 64.47 ± 29.48% to 92.29 ± 14.42% ( p  < 0.001). Percent of questions answered correctly improved in all three categories after the intervention. Correct answers increased from 74.57 ± 24.94% to 95.65 ± 11.48% ( p  < 0.001) for routine daily activities, 51.09 ± 33.9% to 84.78 ± 20.86% ( p  < 0.001) for medical procedures and 64.03 ± 37.36% to 92.57 ± 18.79% ( p  < 0.001) for domestic appliance usage. Conclusion Misconception that can adversely affect pacemaker patient’s quality of life can be corrected by counseling with pictorial based brochures regardless of the patient’s baseline knowledge or education.

Mental health disorders have been identified as a leading cause of disability and premature mortality globally. Social pressure has been associated with mental health issues such as depression, anxiety, and stress. This study assessed the association between social pressure and mental health outcomes among undergraduate students in Karachi, Pakistan. A cross-sectional study was conducted among 460 undergraduate students aged 18–25 years, recruited using non-probability purposive sampling, and enrolled in engineering, medicine, and humanities degree programs across three universities in Karachi, Pakistan. Data was collected using a self-administered questionnaire. Participants’ mental health was assessed using the DASS-21 scale, and social pressure was measured using a composite variable encompassing academic, financial, family, and peer-related pressures. Data was analyzed using STATA version 17, applying ordinal logistic regression. Institutional ethical approval and necessary permissions were obtained prior to data collection. A sample of 400 undergraduate students from three universities in Karachi was analyzed, with a higher proportion of females ( n  = 270; 67.5%) and a mean age of 21.1 ± 0.10 years. For every five-unit increase in social pressure, the odds of moderate to severe depression symptoms increased by 67% (OR = 1.67; 95% CI: 1.29–2.16) among medical students and by 42% (OR = 1.42; 95% CI: 1.13–1.79) among engineering students. The odds of moderate to severe anxiety symptoms increased by 25% (OR = 1.25; 95% CI: 1.12–1.39) among medical students and by 23% (OR = 1.23; 95% CI: 1.01–1.50) among engineering students for every five-unit increase in social pressure. For stress, each five-unit increase in social pressure was associated with a 41% increase in the odds of moderate to severe stress symptoms (OR = 1.41; 95% CI: 1.24–1.59). Students living in joint family systems had higher odds of moderate to severe stress symptoms (OR = 2.38; 95% CI: 1.03–5.49). The findings suggest that medical and engineering students have higher odds of moderate to severe depression, anxiety, and stress symptoms as compared to students enrolled in humanities programs. Further research is needed to better understand the contextual factors contributing to mental health challenges among university students in low-resource settings like Pakistan.

Discontinuation of a contraceptive method soon after its initiation is becoming a public health problem in Low middle income countries and may result in unintended pregnancy and related unwanted consequences. A better understanding of factors behind discontinuation of a modern method would help in designing interventions to continue its use till desired spacing goals are achieved. To determine factors associated with the discontinuation of modern contraceptive methods within six months of its use compared to continued use of modern method for at least six months in low-income areas of Karachi, Pakistan. A community-based case-control study was conducted in low-income areas of Karachi. Cases were 137 users who discontinued a modern contraceptive method within 6 months of initiation and were not using any method at the time of interview, while controls were 276 continuous users of modern method for at least last six months from the time of interview. Information was collected by using a structured questionnaire. Applied logistic regression was used to identify the associated factors for discontinuation. The mean ages of discontinued and continued users were 29.3±5.3 years and 29.2±5.4 years respectively. A larger proportion of the discontinued users had no formal education (43.8%) as compared to the continued users (27.9%). The factors associated with discontinuation of a modern method of contraception were belonging to Sindhi ethnicity [OR: 2.54, 95%CI 1.16-5.57], experiencing side effects [OR: 15.12; 95% CI 7.50-30.51], difficulty in accessing contraceptives by themselves [OR: 0.40, 95%CI 0.19-0.83] and difficulty in reaching clinics for management of the side effects [OR: 4.10, 95%CI 2.38-7.05]. Moreover, women having support from the husband for contraceptive use were less likely to discontinue the method [OR: 0.58, 95% CI 0.34-0.98]. Sindhi ethnicity and side effects of modern methods of contraception were identified as major factors for discontinuation in low-income populations. Similarly, women who had difficulty in travelling to reach clinics for treatment also contributed to discontinuation. Furthermore, women using long acting methods and those supported by their husbands were less likely to discontinue the contraceptive methods. Findings emphasize a need to focus on Sindhi ethnicity and trainings of service providers on management of side effects and provision of high quality of services.

Background There is very little information about the quality of life (QOL) of stroke survivors in LMIC countries with underdeveloped non communicable health infrastructures, who bear two thirds of the global stroke burden. Methodology We used a sequential mix methods approach. First, a quantitative analytical cross-sectional study was conducted on 700 participants, who constituted 350 stroke survivor and their caregiver dyads. QOL of stroke survivor was assessed via Stroke Specific Quality of Life Scale (SSQOLS) whereas QOL of caregivers was assessed through RAND-36. In addition; we assessed complications, psychosocial and functional disability of stroke survivors. Following this quantitative survey, caregivers were qualitatively interviewed to uncover contextually relevant themes that would evade quantitative surveys. Multiple linear regression technique was applied to report adjusted β-coefficients with 95% C.I. Results The QOL study was conducted from January 2014 till June 2014, in two large private and public centers . At each center, 175 dyads were interviewed to ensure representativeness. Median age of stroke survivors was 59(17) years, 68% were male, 60% reported depression and 70% suffered post-stroke complications. The mean SSQOLS score was 164.18 ± 32.30. In the final model severe functional disability [adjβ -33.77(-52.44, -15.22)], depression [adjβ-23.74(-30.61,-16.82)], hospital admissions [adjβ-5.51(-9.23,-1.92)] and severe neurologic pain [adjβ -12.41(-20.10,-4.77)] negatively impacted QOL of stroke survivors ( P < 0.01 ). For caregivers, mean age was 39.18 ± 13.44 years, 51% were female and 34% reported high stress levels. Complementary qualitative study revealed that primary caregivers were depressed, frustrated, isolated and also disappointed by health services. Conclusion The QOL of Stroke survivors as reported by SSQOLS score was better than compared to those reported from other LMIC settings. However, Qualitative triangulation revealed that younger caregivers felt isolated, depressed, overwhelmed and were providing care at great personal cost. There is a need to develop cost effective holistic home support interventions to improve lives of the survivor dyad as a unit. Trial registration NCT02351778 (Registered as Observational Study).

The incidence of HIV among persons who inject drugs (PWIDU) has fallen in many nations, likely due to successes of clean needle/syringe exchange and substance abuse treatment and service programs. However in Pakistan, prevalence rates for PWID have risen dramatically. In several cities, prevalence exceeded 20% by 2009 compared to a 2003 baseline of just 0.5%. However, no cohort study of PWID has ever been conducted. We enrolled a cohort of 636 HIV seronegative PWID registered with three drop-in centers that focus on risk reduction and basic social services in Karachi. Recruitment began in 2009 (March to June) and PWID were followed for two years. We measured incidence rates and risk factors associated with HIV seroconversion. Incidence of HIV was 12.4 per 100 person-years (95% exact Poisson confidence interval [CI]: 10.3-14.9). We followed 474 of 636 HIV seronegative persons (74.5%) for two years, an annual loss to follow-up of <13 per 100 person years. In multivariable Cox regression analysis, HIV seroconversion was associated with non-Muslim religion (Adjusted risk ratio [ARR] = 1.7, 95%CI:1.4, 2.7, p = 0.03), sharing of syringes (AR  = 2.3, 95%CI:1.5, 3.3, p<0.0001), being homeless (ARR = 1.7, 95%CI:1.1, 2.5, p = 0.009), and daily injection of drugs (ARR = 1.1, 95%CI:1.0, 1.3, p = 0.04). Even though all members of the cohort of PWID were attending risk reduction programs, the HIV incidence rate was very high in Karachi from 2009-2011. The project budget was low, yet we were able to retain three-quarters of the population over two years. Absence of opiate substitution therapy and incomplete needle/syringe exchange coverage undermines success in HIV risk reduction.

Background The incidence of HIV among persons who inject drugs (PWIDU) has fallen in many nations, likely due to successes of clean needle/syringe exchange and substance abuse treatment and service programs. However in Pakistan, prevalence rates for PWID have risen dramatically. In several cities, prevalence exceeded 20% by 2009 compared to a 2003 baseline of just 0.5%. However, no cohort study of PWID has ever been conducted. Methods We enrolled a cohort of 636 HIV seronegative PWID registered with three drop-in centers that focus on risk reduction and basic social services in Karachi. Recruitment began in 2009 (March to June) and PWID were followed for two years. We measured incidence rates and risk factors associated with HIV seroconversion. Results Incidence of HIV was 12.4 per 100 person-years (95% exact Poisson confidence interval [CI]: 10.3-14.9). We followed 474 of 636 HIV seronegative persons (74.5%) for two years, an annual loss to follow-up of <13 per 100 person years. In multivariable Cox regression analysis, HIV seroconversion was associated with non-Muslim religion (Adjusted risk ratio [ARR] = 1.7, 95%CI:1.4, 2.7, p = 0.03), sharing of syringes (ARR = 2.3, 95%CI:1.5, 3.3, p<0.0001), being homeless (ARR = 1.7, 95%CI:1.1, 2.5, p = 0.009), and daily injection of drugs (ARR = 1.1, 95%CI:1.0, 1.3, p = 0.04). Conclusions Even though all members of the cohort of PWID were attending risk reduction programs, the HIV incidence rate was very high in Karachi from 2009-2011. The project budget was low, yet we were able to retain three-quarters of the population over two years. Absence of opiate substitution therapy and incomplete needle/syringe exchange coverage undermines success in HIV risk reduction.