Pub Date : 2023-11-16DOI: 10.47144/phj.v56isupplement_2.2673
Reema Qayoom, Aatkah Naseer, Saba Aijaz, Bashir Hanif
Objectives: In Pakistan, cardiovascular risk factors for acute myocardial infarction are increasing. There are few studies available on atherosclerotic risk factors in young patients and its outcome The purpose of this study was to compare pattern of traditional CVD risk factors, hospital mortality and major adverse cardiac events at discharge in young versus old patients (≤45years and above 45 years age respectively) admitted with STEMI and undergoing primary PCI. Methodology: This retrospective cohort study was conducted on consecutive patients presenting with STEMI between June 2013 and June 2018 in a single centre cardiac only tertiary care setup. Institute’s registry is fashioned along and is affiliated with US NCDR. Patients with cardiac arrest or cardiogenic shock at arrival were excluded. MACE was defined as post PCI cardiac arrest or cardiogenic shock, heart failure, major bleed or hospital death. Models were built using stepwise forward logistic regression method. Results: Total of 5343 patients were admitted with STEMI during study period, after exclusion data of 1642 patients were analyzed. Among young patients, the frequency of the male gender, any tobacco use and family history of premature coronary artery disease were significantly higher (all p values < 0.001). While in older STEMI patients frequency of heart failure, hypertension, prior myocardial infarction, diabetes mellitus ,abnormal creatinine clearance (<90 mL/min/1.73 m²) , multi-vessel coronary disease, advanced Killip class and higher body mass index was more prevalent (all P<0.001). Among young patients advanced Killip class and femoral access site(all P values <0.001), diabetes mellitus (p=0.03), abnormal creatinine clearance(p=0.04),and left ventricular ejection fraction less than 40%(p=0.01), were more significant in-hospital mortality predictor whereas advanced Killip class, Left ventricular ejection fraction less than 40% male gender(p=0.04), diabetes mellitus(p=0.001),femoral access site(p=0.001), and Left ventricular ejection fraction less than 40% were more significant MACE predictors (all P<0.001). Conclusion: There were no significant difference in hospital mortality and MACE among young versus old STEMI patients when adjusted for diabetes mellitus, abnormal creatinine clearance (<90 mL/min/1.73 m²), multi-vessel coronary disease, advanced Killip class. Tobacco use is the main modifiable risk factors for young patients with STEMI. Surprisingly, being a woman and having a positive family history with premature coronary artery disease were protective.
{"title":"Risk Factor Profile and Hospital Outcomes in Patients ≤ 45 Years vs. >45 Years of Age Presenting with Acute ST-Segment Elevation Myocardial Infarction","authors":"Reema Qayoom, Aatkah Naseer, Saba Aijaz, Bashir Hanif","doi":"10.47144/phj.v56isupplement_2.2673","DOIUrl":"https://doi.org/10.47144/phj.v56isupplement_2.2673","url":null,"abstract":"Objectives: In Pakistan, cardiovascular risk factors for acute myocardial infarction are increasing. There are few studies available on atherosclerotic risk factors in young patients and its outcome The purpose of this study was to compare pattern of traditional CVD risk factors, hospital mortality and major adverse cardiac events at discharge in young versus old patients (≤45years and above 45 years age respectively) admitted with STEMI and undergoing primary PCI. Methodology: This retrospective cohort study was conducted on consecutive patients presenting with STEMI between June 2013 and June 2018 in a single centre cardiac only tertiary care setup. Institute’s registry is fashioned along and is affiliated with US NCDR. Patients with cardiac arrest or cardiogenic shock at arrival were excluded. MACE was defined as post PCI cardiac arrest or cardiogenic shock, heart failure, major bleed or hospital death. Models were built using stepwise forward logistic regression method. Results: Total of 5343 patients were admitted with STEMI during study period, after exclusion data of 1642 patients were analyzed. Among young patients, the frequency of the male gender, any tobacco use and family history of premature coronary artery disease were significantly higher (all p values < 0.001). While in older STEMI patients frequency of heart failure, hypertension, prior myocardial infarction, diabetes mellitus ,abnormal creatinine clearance (<90 mL/min/1.73 m²) , multi-vessel coronary disease, advanced Killip class and higher body mass index was more prevalent (all P<0.001). Among young patients advanced Killip class and femoral access site(all P values <0.001), diabetes mellitus (p=0.03), abnormal creatinine clearance(p=0.04),and left ventricular ejection fraction less than 40%(p=0.01), were more significant in-hospital mortality predictor whereas advanced Killip class, Left ventricular ejection fraction less than 40% male gender(p=0.04), diabetes mellitus(p=0.001),femoral access site(p=0.001), and Left ventricular ejection fraction less than 40% were more significant MACE predictors (all P<0.001). Conclusion: There were no significant difference in hospital mortality and MACE among young versus old STEMI patients when adjusted for diabetes mellitus, abnormal creatinine clearance (<90 mL/min/1.73 m²), multi-vessel coronary disease, advanced Killip class. Tobacco use is the main modifiable risk factors for young patients with STEMI. Surprisingly, being a woman and having a positive family history with premature coronary artery disease were protective.","PeriodicalId":42273,"journal":{"name":"Pakistan Heart Journal","volume":"21 1","pages":""},"PeriodicalIF":0.1,"publicationDate":"2023-11-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139269824","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-16DOI: 10.47144/phj.v56isupplement_2.2676
Pirbhat Shams, Fateh Ali Tipoo Sultan, Aiman Sultan, Umair Javed
Objectives: To estimate the prevalence of non-calcified coronary artery disease in patients with chest pain and a zero coronary artery calcium score, and to assess the prognostic significance of a zero coronary artery calcium score in these symptomatic patients. Methodology: All consecutive patients who underwent a CT coronary angiogram (CTCA) for evaluation of angina or angina-equivalent symptoms from 2009 to December 2020 were enrolled retrospectively. Patients with prior myocardial infarction, history of revascularization, and congenital heart disease were excluded. Follow-up data was collected by using the hospital's electronic patient record system and telephone communication. The endpoint, major-adverse cardiovascular events (MACE) was defined as the total of cardiac death, non-fatal myocardial infarction, and/or non-elective revascularization. Results: A total of 534 patients were enrolled after final exclusion. The mean age was 53 years ± 11. Males constituted 68.4% of the study population. Dyslipidemia was the most common co-morbid condition identified (50%), followed by diabetes (18.4%) and hypertension (3.6%). Chest pain was the most common presenting complaint (97.4%) followed by dyspnea. At least 28.8% of patients with zero CAC scores had the presence of coronary artery disease (soft plaque) of any degree. Obstructive CAD (>50%) was present in 5.8% of patients. Follow-up was available for 61.4% of patients. The mean follow-up duration was 96.6 months ± 49.8 (range 21 – 194 months). All-cause Major Adverse Cardiovascular Event (MACE) was observed in 8.8% of patients. The most common MACE outcome was angina (3.96%) and all-cause mortality (3%). Only 2.7% required revascularization on follow-up with 1.2% having myocardial infarction and non-urgent revascularization. The baseline characteristics, all-cause MACE (p = 0.79), mortality (0.82), angina (p = 0.765), revascularization (p = 0.45), non-fatal MI, and non-elective revascularization (p = 0.6) did not differ significantly in patients with and without obstructive CAD. The baseline characteristics did not differ significantly between patients with and without MACE. Conclusion: The incidence of soft plaque in this South Asian cohort is higher than that reported in international studies. However, in symptomatic South Asians, a CAC score of zero carries a good long-term prognosis, irrespective of the degree of CAD.
{"title":"Prognosis of Zero Coronary Artery Calcium Score in Symptomatic Patients of South Asian Descent – An Experience From a Tertiary Care Center in Pakistan","authors":"Pirbhat Shams, Fateh Ali Tipoo Sultan, Aiman Sultan, Umair Javed","doi":"10.47144/phj.v56isupplement_2.2676","DOIUrl":"https://doi.org/10.47144/phj.v56isupplement_2.2676","url":null,"abstract":"Objectives: To estimate the prevalence of non-calcified coronary artery disease in patients with chest pain and a zero coronary artery calcium score, and to assess the prognostic significance of a zero coronary artery calcium score in these symptomatic patients. Methodology: All consecutive patients who underwent a CT coronary angiogram (CTCA) for evaluation of angina or angina-equivalent symptoms from 2009 to December 2020 were enrolled retrospectively. Patients with prior myocardial infarction, history of revascularization, and congenital heart disease were excluded. Follow-up data was collected by using the hospital's electronic patient record system and telephone communication. The endpoint, major-adverse cardiovascular events (MACE) was defined as the total of cardiac death, non-fatal myocardial infarction, and/or non-elective revascularization. Results: A total of 534 patients were enrolled after final exclusion. The mean age was 53 years ± 11. Males constituted 68.4% of the study population. Dyslipidemia was the most common co-morbid condition identified (50%), followed by diabetes (18.4%) and hypertension (3.6%). Chest pain was the most common presenting complaint (97.4%) followed by dyspnea. At least 28.8% of patients with zero CAC scores had the presence of coronary artery disease (soft plaque) of any degree. Obstructive CAD (>50%) was present in 5.8% of patients. Follow-up was available for 61.4% of patients. The mean follow-up duration was 96.6 months ± 49.8 (range 21 – 194 months). All-cause Major Adverse Cardiovascular Event (MACE) was observed in 8.8% of patients. The most common MACE outcome was angina (3.96%) and all-cause mortality (3%). Only 2.7% required revascularization on follow-up with 1.2% having myocardial infarction and non-urgent revascularization. The baseline characteristics, all-cause MACE (p = 0.79), mortality (0.82), angina (p = 0.765), revascularization (p = 0.45), non-fatal MI, and non-elective revascularization (p = 0.6) did not differ significantly in patients with and without obstructive CAD. The baseline characteristics did not differ significantly between patients with and without MACE. Conclusion: The incidence of soft plaque in this South Asian cohort is higher than that reported in international studies. However, in symptomatic South Asians, a CAC score of zero carries a good long-term prognosis, irrespective of the degree of CAD.","PeriodicalId":42273,"journal":{"name":"Pakistan Heart Journal","volume":"14 6","pages":""},"PeriodicalIF":0.1,"publicationDate":"2023-11-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139270331","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-16DOI: 10.47144/phj.v56isupplement_2.2679
Javaid Jalbani, K. I. Bhatti, Tariq Sallar
Objectives: To evaluate the admission neutrophil-to-lymphocyte ratio (NLR) for risk stratification for in-hospital out-comes and complications in non-ST-elevation acute coronary syndrome (non-ST-ACS) patients. Methodology: Methods: We recruited consecutive patients with non-ST-ACS. The NLR was obtained and stratified as low, inter- mediate, and high-risk based on <3.0, 3.0e6.0, and >6.0, respectively. The new ST-T changes, arrhythmias, contrast-induced nephropathy (CIN), and mortality were recorded. Results: Results: Median NLR was 3 [2.1-5.3] for 346 patients with 19.9% and 30.6% in high- and intermediate-risk group. New ST-T changes were observed in 3.5% (12) out of which 8, 3, and 1 patient in low, intermediate, and high-risk group (p = 0.424), respectively. Arrhythmias were observed in 5.8% (20) with 7, 5, and 8 patients in low, intermediate, and high- risk group (p = 0.067), respectively. CIN was observed in 4.9% (17) with 5, 5, and 7 in low, intermediate, and high-risk group (p = 0.064), respectively. In-hospital mortality was recorded in 1.4% (5) with 2 and 3 patients in high and low-risk group (p = 0.260), respectively. Conclusion: A significant number of non-ST-ACS patients fall in the high-risk category of NLR. Although, the association between NLR and in-hospital mortality and adverse events was not statistically significant but relatively higher rates of events were observed in high risk group.
{"title":"The Role of Neutrophil to Lymphocytes Ratio and It's Common Clinical Outcomes Amount the Patient with Non ST Elevation Acute Coronary Syndrome","authors":"Javaid Jalbani, K. I. Bhatti, Tariq Sallar","doi":"10.47144/phj.v56isupplement_2.2679","DOIUrl":"https://doi.org/10.47144/phj.v56isupplement_2.2679","url":null,"abstract":"Objectives: To evaluate the admission neutrophil-to-lymphocyte ratio (NLR) for risk stratification for in-hospital out-comes and complications in non-ST-elevation acute coronary syndrome (non-ST-ACS) patients. Methodology: Methods: We recruited consecutive patients with non-ST-ACS. The NLR was obtained and stratified as low, inter- mediate, and high-risk based on <3.0, 3.0e6.0, and >6.0, respectively. The new ST-T changes, arrhythmias, contrast-induced nephropathy (CIN), and mortality were recorded. Results: Results: Median NLR was 3 [2.1-5.3] for 346 patients with 19.9% and 30.6% in high- and intermediate-risk group. New ST-T changes were observed in 3.5% (12) out of which 8, 3, and 1 patient in low, intermediate, and high-risk group (p = 0.424), respectively. Arrhythmias were observed in 5.8% (20) with 7, 5, and 8 patients in low, intermediate, and high- risk group (p = 0.067), respectively. CIN was observed in 4.9% (17) with 5, 5, and 7 in low, intermediate, and high-risk group (p = 0.064), respectively. In-hospital mortality was recorded in 1.4% (5) with 2 and 3 patients in high and low-risk group (p = 0.260), respectively. Conclusion: A significant number of non-ST-ACS patients fall in the high-risk category of NLR. Although, the association between NLR and in-hospital mortality and adverse events was not statistically significant but relatively higher rates of events were observed in high risk group.","PeriodicalId":42273,"journal":{"name":"Pakistan Heart Journal","volume":"10 1","pages":""},"PeriodicalIF":0.1,"publicationDate":"2023-11-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139269158","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-16DOI: 10.47144/phj.v56isupplement_2.2686
Nazeef Ullah
Objectives: The study aimed to investigate the association between CP2C19*2 loss of function polymorphism and acute coronary syndrome (ACS) patients receiving Clopidogrel. It compared genotype frequencies of heterozygous GA, homozygous GG, and homozygous AA between ACS patients and healthy controls. The study assessed the statistical significance of the association in the Pakistani cohort. It contributed to understanding the role of genetic polymorphisms in response to Clopidogrel therapy in ACS patients and provided insights into the need for pharmacogenomics testing for patients with CAD, particularly in the Asian population, who are poor metabolizers and require long-term Clopidogrel therapy. Methodology: COHORT Study. Results: The study found no statistically significant association between the CYP2C19*2 loss of function polymorphism and acute coronary syndrome (ACS) in the Pakistani cohort. The frequency of the CP2C19*2 heterozygous GA genotype was 38.3% in ACS patients and 29.5% in control subjects, while the homozygous GG genotype was 58.7% in patients and 59.0% in controls. The homozygous AA genotype was 3.4% in patients and 11.4% in controls. The genotype frequency analysis showed that the wild type GG genotype was lower in patients (58.7%) compared to controls (59.0%), while the mutant AA genotype was also lower in patients (3.4%) compared to controls (11.4%). The heterozygous GA genotype was higher in patients (38.3%) compared to controls (29.5%). The population studied was in Hardy Weinberg equilibrium, with a frequency of mutant allele A at 0.26 and wild type allele G at 0.73. Conclusion: The study concludes that the CYP2C19*2 loss of function polymorphism is not associated with acute coronary syndrome (ACS) in the Pakistani cohort. The distribution of the CP2C19*2 genetic polymorphism was not statistically significant between ACS patients and healthy controls. The genotype frequency analysis showed no significant differences in the distribution of the heterozygous GA, homozygous GG, and homozygous AA genotypes between the patient and control groups. The population studied was in Hardy Weinberg equilibrium, with a frequency of mutant allele A at 0.26 and wild type allele G at 0.73.
研究目的本研究旨在探讨 CP2C19*2 功能缺失多态性与接受氯吡格雷治疗的急性冠状动脉综合征（ACS）患者之间的关系。研究比较了 ACS 患者和健康对照组之间杂合 GA、同源 GG 和同源 AA 的基因型频率。该研究评估了巴基斯坦队列中这种关联的统计学意义。该研究有助于了解基因多态性在 ACS 患者对氯吡格雷治疗反应中的作用，并深入了解了对代谢不良且需要长期氯吡格雷治疗的 CAD 患者（尤其是亚洲人群）进行药物基因组学检测的必要性。 研究方法：COHORT 研究。 研究结果研究发现，在巴基斯坦队列中，CYP2C19*2 功能缺失多态性与急性冠状动脉综合征（ACS）无统计学意义。CP2C19*2 杂合 GA 基因型在 ACS 患者中的频率为 38.3%，在对照组中的频率为 29.5%，而同源 GG 基因型在患者中的频率为 58.7%，在对照组中的频率为 59.0%。同源 AA 基因型在患者中占 3.4%，在对照组中占 11.4%。 基因型频率分析表明，与对照组（59.0%）相比，野生型 GG 基因型在患者中的比例较低（58.7%），而与对照组（11.4%）相比，突变型 AA 基因型在患者中的比例也较低（3.4%）。与对照组（29.5%）相比，患者的杂合 GA 基因型更高（38.3%）。 研究人群处于哈代-温伯格平衡状态，突变等位基因 A 的频率为 0.26，野生型等位基因 G 的频率为 0.73。 结论研究得出结论，在巴基斯坦队列中，CYP2C19*2 功能缺失多态性与急性冠状动脉综合征（ACS）无关。CP2C19*2 基因多态性的分布在 ACS 患者和健康对照组之间没有统计学意义。 基因型频率分析显示，杂合GA、同源GG和同源AA基因型的分布在患者组和对照组之间无明显差异。 所研究的人群处于哈代-温伯格平衡状态，突变等位基因A的频率为0.26，野生型等位基因G的频率为0.73。
{"title":"Cytochrome P450 2C19*2 Genetic Polymorphism in Patients with Acute Coronary Syndrome","authors":"Nazeef Ullah","doi":"10.47144/phj.v56isupplement_2.2686","DOIUrl":"https://doi.org/10.47144/phj.v56isupplement_2.2686","url":null,"abstract":"Objectives: The study aimed to investigate the association between CP2C19*2 loss of function polymorphism and acute coronary syndrome (ACS) patients receiving Clopidogrel. It compared genotype frequencies of heterozygous GA, homozygous GG, and homozygous AA between ACS patients and healthy controls. The study assessed the statistical significance of the association in the Pakistani cohort. It contributed to understanding the role of genetic polymorphisms in response to Clopidogrel therapy in ACS patients and provided insights into the need for pharmacogenomics testing for patients with CAD, particularly in the Asian population, who are poor metabolizers and require long-term Clopidogrel therapy. Methodology: COHORT Study. Results: The study found no statistically significant association between the CYP2C19*2 loss of function polymorphism and acute coronary syndrome (ACS) in the Pakistani cohort. The frequency of the CP2C19*2 heterozygous GA genotype was 38.3% in ACS patients and 29.5% in control subjects, while the homozygous GG genotype was 58.7% in patients and 59.0% in controls. The homozygous AA genotype was 3.4% in patients and 11.4% in controls. The genotype frequency analysis showed that the wild type GG genotype was lower in patients (58.7%) compared to controls (59.0%), while the mutant AA genotype was also lower in patients (3.4%) compared to controls (11.4%). The heterozygous GA genotype was higher in patients (38.3%) compared to controls (29.5%). The population studied was in Hardy Weinberg equilibrium, with a frequency of mutant allele A at 0.26 and wild type allele G at 0.73. Conclusion: The study concludes that the CYP2C19*2 loss of function polymorphism is not associated with acute coronary syndrome (ACS) in the Pakistani cohort. The distribution of the CP2C19*2 genetic polymorphism was not statistically significant between ACS patients and healthy controls. The genotype frequency analysis showed no significant differences in the distribution of the heterozygous GA, homozygous GG, and homozygous AA genotypes between the patient and control groups. The population studied was in Hardy Weinberg equilibrium, with a frequency of mutant allele A at 0.26 and wild type allele G at 0.73.","PeriodicalId":42273,"journal":{"name":"Pakistan Heart Journal","volume":"38 1","pages":""},"PeriodicalIF":0.1,"publicationDate":"2023-11-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139269826","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Shakir Zada, Arshad Ali, Ibrar Hussain, Romana Pirah, Shueeta Kumari, Aziz Ur Rehman Memon, Manadia Fatima, Zahid Jamal
Objectives: This study aimed to determine the frequency of multi-vessel coronary artery disease (MVD) in diabetic patients presenting with anterior wall myocardial infarction (AWMI). Methodology: In this descriptive cross-sectional study, we included diabetic patients with AWMI aged between 30-70 years. Patients with either a history of clinical diagnosis based on HbA1c >6.5% / fasting blood sugar > 126 mg/dL/ random blood sugar >200 mg/dL or taking anti-hyperglycemic treatment for at least six months were taken as diabetics. Patients with angiographic evidence of significant (>70%) stenosis in two major epicardial vessels were categorized for MVD. Results: A total of 196 diabetic patients with anterior wall MI were included. Of which the mean age was 57.6±12.3 years, and 128 (65.3%) were male patients. MVD was observed in 91 (46.4%) patients. The MVD was found to be associated with a BMI ≥ 24 kg/m2 with a frequency of 51.5% vs. 35%; p=0.033, as compared to a BMI < 24 kg/m2. The frequency of MVD was higher among middle-class patients, with a frequency of 36.2%, 58.3%, and 39.5% (p=0.014) for patients in the low, middle, and upper classes, respectively. Similarly, the MVD frequency was higher among patients with hypertension (60.6% vs. 28.7%) and hyperlipidemia (62.1% vs. 38.5%) compared to non-hypertensive and non-hyperlipidemia, respectively. Conclusion: It is to be concluded that MVD is highly prevalent in diabetic patients presenting with AWMI, and it was found to be associated with BMI ≥ 24 kg/m2, middle class, hypertension, and hyperlipidemia.
目的:本研究旨在确定伴有前壁心肌梗死(AWMI)的糖尿病患者多支冠状动脉病变(MVD)的发生率。方法:在这项描述性横断面研究中，我们纳入了年龄在30-70岁之间的糖尿病AWMI患者。HbA1c + gt;6.5% /空腹血糖+ gt有临床诊断史;126 mg/dL/随机血糖及200 mg/dL或服用降糖治疗至少6个月者为糖尿病患者。血管造影显示两条主要心外膜血管明显狭窄(>70%)的患者被归类为MVD。结果:共纳入196例糖尿病前壁心肌梗死患者。其中平均年龄57.6±12.3岁，男性128例(65.3%)。91例(46.4%)患者出现MVD。BMI≥24 kg/m2与MVD相关的频率分别为51.5%和35%;p=0.033，与BMI <24 kg / m2。中产阶级的MVD发生率较高，下层、中层和上层的MVD发生率分别为36.2%、58.3%和39.5% (p=0.014)。同样，高血压(60.6% vs. 28.7%)和高脂血症(62.1% vs. 38.5%)患者的MVD频率分别高于非高血压和非高脂血症患者。结论:MVD在糖尿病AWMI患者中高发，且与BMI≥24 kg/m2、中产阶级、高血压、高脂血症相关。
{"title":"Multi-vessel Coronary Artery Disease in Diabetic Patients Presenting with Anterior Wall Myocardial Infraction","authors":"Shakir Zada, Arshad Ali, Ibrar Hussain, Romana Pirah, Shueeta Kumari, Aziz Ur Rehman Memon, Manadia Fatima, Zahid Jamal","doi":"10.47144/phj.v56i3.2558","DOIUrl":"https://doi.org/10.47144/phj.v56i3.2558","url":null,"abstract":"Objectives: This study aimed to determine the frequency of multi-vessel coronary artery disease (MVD) in diabetic patients presenting with anterior wall myocardial infarction (AWMI). Methodology: In this descriptive cross-sectional study, we included diabetic patients with AWMI aged between 30-70 years. Patients with either a history of clinical diagnosis based on HbA1c >6.5% / fasting blood sugar > 126 mg/dL/ random blood sugar >200 mg/dL or taking anti-hyperglycemic treatment for at least six months were taken as diabetics. Patients with angiographic evidence of significant (>70%) stenosis in two major epicardial vessels were categorized for MVD. Results: A total of 196 diabetic patients with anterior wall MI were included. Of which the mean age was 57.6±12.3 years, and 128 (65.3%) were male patients. MVD was observed in 91 (46.4%) patients. The MVD was found to be associated with a BMI ≥ 24 kg/m2 with a frequency of 51.5% vs. 35%; p=0.033, as compared to a BMI < 24 kg/m2. The frequency of MVD was higher among middle-class patients, with a frequency of 36.2%, 58.3%, and 39.5% (p=0.014) for patients in the low, middle, and upper classes, respectively. Similarly, the MVD frequency was higher among patients with hypertension (60.6% vs. 28.7%) and hyperlipidemia (62.1% vs. 38.5%) compared to non-hypertensive and non-hyperlipidemia, respectively. Conclusion: It is to be concluded that MVD is highly prevalent in diabetic patients presenting with AWMI, and it was found to be associated with BMI ≥ 24 kg/m2, middle class, hypertension, and hyperlipidemia.","PeriodicalId":42273,"journal":{"name":"Pakistan Heart Journal","volume":"45 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136343752","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Gian Chand, Abdul Hameed, Rukhsar Bibi, Iram Jehan Balouch, Ijaz Ul Haq, Muhammad Tahseen Raza, Ahmed Raheem
Objectives: The objective of this updated meta-analysis is to consolidate high-quality peer-reviewed clinical evidence, including trials and observational studies, to evaluate the efficacy and safety of “direct oral anticoagulants (DOACs)” versus “vitamin K antagonists (VKAs)” for treating “left ventricular thrombus (LVT)”. Methodology: We included studies of either "observational" or "experimental" in nature reported original data for the head-to-head comparison of "DOACs" and "VKAs" for the treatment of LVT. The efficacy-related outcome of interest was "thrombus resolution" and safety-related outcomes of interest were; "mortality", "major bleeding", and "stroke". The “risk ratios (RRs)” for each outcome variable were calculated using the “Mantel-Haenszel method”. Results: The analysis included 19 studies comprised of 3,027 patients diagnosed with LVT. Among them, 881 received DOAC treatment, while 2,146 were treated with VKAs. DOACs showed comparable rates of LVT resolution (RR: 1.00 [0.93 – 1.08]), lower mortality incidence (RR: 0.65 [0.51 – 0.84]), similar stroke incidence (RR: 0.83 [0.61 – 1.14]), and similar major bleeding incidence (RR: 0.71 [0.50 – 1.00]) compared to VKAs. Conclusion: The meta-analysis indicates that DOACs are as effective as VKAs for treating LVT, showing comparable thrombus resolution rates, lower all-cause mortality, similar stroke risks, and clinically relevant bleeding across studies. However, these conclusions are limited by the lack of evidence from large-scale randomized studies and high-quality real-life clinical data.
{"title":"A Meta-Analysis for the Efficacy and Safety of Direct Oral Anticoagulants versus Vitamin K Antagonists for Left Ventricular Thrombus","authors":"Gian Chand, Abdul Hameed, Rukhsar Bibi, Iram Jehan Balouch, Ijaz Ul Haq, Muhammad Tahseen Raza, Ahmed Raheem","doi":"10.47144/phj.v56i3.2611","DOIUrl":"https://doi.org/10.47144/phj.v56i3.2611","url":null,"abstract":"Objectives: The objective of this updated meta-analysis is to consolidate high-quality peer-reviewed clinical evidence, including trials and observational studies, to evaluate the efficacy and safety of “direct oral anticoagulants (DOACs)” versus “vitamin K antagonists (VKAs)” for treating “left ventricular thrombus (LVT)”. Methodology: We included studies of either \"observational\" or \"experimental\" in nature reported original data for the head-to-head comparison of \"DOACs\" and \"VKAs\" for the treatment of LVT. The efficacy-related outcome of interest was \"thrombus resolution\" and safety-related outcomes of interest were; \"mortality\", \"major bleeding\", and \"stroke\". The “risk ratios (RRs)” for each outcome variable were calculated using the “Mantel-Haenszel method”. Results: The analysis included 19 studies comprised of 3,027 patients diagnosed with LVT. Among them, 881 received DOAC treatment, while 2,146 were treated with VKAs. DOACs showed comparable rates of LVT resolution (RR: 1.00 [0.93 – 1.08]), lower mortality incidence (RR: 0.65 [0.51 – 0.84]), similar stroke incidence (RR: 0.83 [0.61 – 1.14]), and similar major bleeding incidence (RR: 0.71 [0.50 – 1.00]) compared to VKAs. Conclusion: The meta-analysis indicates that DOACs are as effective as VKAs for treating LVT, showing comparable thrombus resolution rates, lower all-cause mortality, similar stroke risks, and clinically relevant bleeding across studies. However, these conclusions are limited by the lack of evidence from large-scale randomized studies and high-quality real-life clinical data.","PeriodicalId":42273,"journal":{"name":"Pakistan Heart Journal","volume":"15 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136343754","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Cardiovascular diseases (CVD) are a prevalent health concern within the general population of Pakistan, where the average lifespan is notably lower than the global average, with men typically living to 67 years and women to 69 years. According to the 2019 Global Burden of Disease study, Pakistan had an estimated age-standardized incidence rate of CVD at 918.18 per 100,000 (compared to the global rate of 684.33 per 100,000), along with an age-standardized death rate of 357.88 per 100,000 (globally, this rate is 239.85 per 100,000).1 Coronary heart disease (CHD), as revealed by the Framingham Heart Study focusing on individuals aged 40 to 94 without prior heart disease, displayed a lifetime risk of 49% for men and 32% for women when reaching the age of 40.2 There has been a declining trend in death rates in the United States attributed to CVD, CHD, and stroke since 1975. Data from 2000 to 2008 also indicate a decline in CHD mortality.3 Worryingly, the World Health Organization (WHO) reports a concerning rise in CHD-related fatalities in Pakistan. In 2020, 240,720 individuals died due to CHD, accounting for 16.49% of all deaths. This highlights an escalating trend of CHD-related mortality in Pakistan. It's important to note that most individuals presenting with cardiac events have one or more established or borderline risk factors aside from age and gender.4-6 While some essential risk factors are discernible, others may remain elusive. The screening of these risk factors and the evidence for targeted therapeutic interventions are still emerging and require further exploration.7 The starting point for assessing CVD risk factors is variables used to predict major cardiovascular events. These include age, sex, blood pressure, cholesterol levels, diabetes mellitus, and smoking status. Although risk assessment tools like the Pooled Cohort Equation in 2014 and Astro-CHARM have been developed, they have yet to provide satisfactory assessments for potential new CVD risk factors.8 CHD is recognized as a multifactorial disorder resulting from genetic and environmental factors interplay. Environmental risk factors have been identified in approximately 80% of CHD cases.9 Several risk scores, such as the Framingham Risk Score, PROCAM, Reynolds Risk Score, and QRISK 2, have been proposed to guide the use of statins in high-risk groups.10-14 Yet, these risk scores often lack precision and may either overestimate or underestimate future CHD events.15,16 The variation in disease susceptibility among individuals with similar environmental factors and conventional coronary artery disease risk factors (CRFs) may be attributed to genetic variations.17 Genetic analysis can potentially enhance risk discrimination beyond the consideration of CRFs alone. Family history of heart disease, accounting for more than 40% of risk estimation, has long been considered a part of CRFs.18 Candidate gene studies have been conducted to identify common variants in genes associated with d
{"title":"Genetics and Ischemic Heart Disease: Should We Opt for Genetic Testing for Primary Prevention?","authors":"Tariq Ashraf, Taseer Ahmed, Mehir-un-Nisa Iqbal, Asif Nadeem","doi":"10.47144/phj.v56i3.2642","DOIUrl":"https://doi.org/10.47144/phj.v56i3.2642","url":null,"abstract":"Cardiovascular diseases (CVD) are a prevalent health concern within the general population of Pakistan, where the average lifespan is notably lower than the global average, with men typically living to 67 years and women to 69 years. According to the 2019 Global Burden of Disease study, Pakistan had an estimated age-standardized incidence rate of CVD at 918.18 per 100,000 (compared to the global rate of 684.33 per 100,000), along with an age-standardized death rate of 357.88 per 100,000 (globally, this rate is 239.85 per 100,000).1 Coronary heart disease (CHD), as revealed by the Framingham Heart Study focusing on individuals aged 40 to 94 without prior heart disease, displayed a lifetime risk of 49% for men and 32% for women when reaching the age of 40.2 There has been a declining trend in death rates in the United States attributed to CVD, CHD, and stroke since 1975. Data from 2000 to 2008 also indicate a decline in CHD mortality.3 Worryingly, the World Health Organization (WHO) reports a concerning rise in CHD-related fatalities in Pakistan. In 2020, 240,720 individuals died due to CHD, accounting for 16.49% of all deaths. This highlights an escalating trend of CHD-related mortality in Pakistan. It's important to note that most individuals presenting with cardiac events have one or more established or borderline risk factors aside from age and gender.4-6 While some essential risk factors are discernible, others may remain elusive. The screening of these risk factors and the evidence for targeted therapeutic interventions are still emerging and require further exploration.7 The starting point for assessing CVD risk factors is variables used to predict major cardiovascular events. These include age, sex, blood pressure, cholesterol levels, diabetes mellitus, and smoking status. Although risk assessment tools like the Pooled Cohort Equation in 2014 and Astro-CHARM have been developed, they have yet to provide satisfactory assessments for potential new CVD risk factors.8 CHD is recognized as a multifactorial disorder resulting from genetic and environmental factors interplay. Environmental risk factors have been identified in approximately 80% of CHD cases.9 Several risk scores, such as the Framingham Risk Score, PROCAM, Reynolds Risk Score, and QRISK 2, have been proposed to guide the use of statins in high-risk groups.10-14 Yet, these risk scores often lack precision and may either overestimate or underestimate future CHD events.15,16 The variation in disease susceptibility among individuals with similar environmental factors and conventional coronary artery disease risk factors (CRFs) may be attributed to genetic variations.17 Genetic analysis can potentially enhance risk discrimination beyond the consideration of CRFs alone. Family history of heart disease, accounting for more than 40% of risk estimation, has long been considered a part of CRFs.18 Candidate gene studies have been conducted to identify common variants in genes associated with d","PeriodicalId":42273,"journal":{"name":"Pakistan Heart Journal","volume":"161 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136343746","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abdul Ghaffar Memon, Muhammad Nauman Khan, Hesham Naeem, Fazal Aziz Mian, Muhammad Imran Khan, Farooq Ahmad, Ahmad Fawad, Khalid Razaq, Abdul Rab Shaikh
Objectives: The study aims to evaluate the severity of heart failure (HF) and its impact on the patient's quality of life (QoL). Methodology: A multicenter, observational study was conducted across 100 medical facilities in Pakistan. Symptomatic HF patients (NYHA Class-II to IV) diagnosed ≥ 1 year ago, aged ≥ 18 years, and advised for echocardiography were invited. A total of 961 patients agreed to participate. HF severity was assessed based on ejection fraction (EF %) and NYHA class. The Kansas City Cardiomyopathy Questionnaire (KCCQ) was used to assess the effect of HF on the patient's QoL. Results: The patients' overall health status exhibited poor scores, with a mean KCCQ score of 20.26±8.34. Concerning left ventricular ejection fraction (LVEF), 25.9% of patients displayed moderate dysfunction (LVEF 30% to 39%), while 29.1% had severe dysfunction (LVEF < 30%). The distribution across NYHA classes was Class II included 451 patients (46.9%), Class III included 317 patients (33.0%), and Class IV included 193 patients (20.1%). High-quality-of-life (HR-QoL) assessments using the KCCQ exhibited significant correlations with both LVEF (rs=-0.394, p<0.01) and NYHA class (rs=-0.615, p<0.01). Notably, the mean KCCQ score displayed considerable variation across NYHA classes, Class II had a mean score of 25.42±7.95, Class III had 20.90±7.67, and Class IV had 16.41±8.94. Significant predictors of quality of life (KCCQ score) included age and NYHA. Conclusion: It is concluded from the study results that HR-QoL is significantly correlated with the severity of HF based on ejection fraction and NYHA class.
{"title":"Prevalence of Severity-based Evaluation of Heart Failure (PROBE) and its Impact on Health-related Quality of Life: An Observational Study","authors":"Abdul Ghaffar Memon, Muhammad Nauman Khan, Hesham Naeem, Fazal Aziz Mian, Muhammad Imran Khan, Farooq Ahmad, Ahmad Fawad, Khalid Razaq, Abdul Rab Shaikh","doi":"10.47144/phj.v56i3.2527","DOIUrl":"https://doi.org/10.47144/phj.v56i3.2527","url":null,"abstract":"Objectives: The study aims to evaluate the severity of heart failure (HF) and its impact on the patient's quality of life (QoL). Methodology: A multicenter, observational study was conducted across 100 medical facilities in Pakistan. Symptomatic HF patients (NYHA Class-II to IV) diagnosed ≥ 1 year ago, aged ≥ 18 years, and advised for echocardiography were invited. A total of 961 patients agreed to participate. HF severity was assessed based on ejection fraction (EF %) and NYHA class. The Kansas City Cardiomyopathy Questionnaire (KCCQ) was used to assess the effect of HF on the patient's QoL. Results: The patients' overall health status exhibited poor scores, with a mean KCCQ score of 20.26±8.34. Concerning left ventricular ejection fraction (LVEF), 25.9% of patients displayed moderate dysfunction (LVEF 30% to 39%), while 29.1% had severe dysfunction (LVEF < 30%). The distribution across NYHA classes was Class II included 451 patients (46.9%), Class III included 317 patients (33.0%), and Class IV included 193 patients (20.1%). High-quality-of-life (HR-QoL) assessments using the KCCQ exhibited significant correlations with both LVEF (rs=-0.394, p<0.01) and NYHA class (rs=-0.615, p<0.01). Notably, the mean KCCQ score displayed considerable variation across NYHA classes, Class II had a mean score of 25.42±7.95, Class III had 20.90±7.67, and Class IV had 16.41±8.94. Significant predictors of quality of life (KCCQ score) included age and NYHA. Conclusion: It is concluded from the study results that HR-QoL is significantly correlated with the severity of HF based on ejection fraction and NYHA class.","PeriodicalId":42273,"journal":{"name":"Pakistan Heart Journal","volume":"45 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136342782","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Nimra Ashraf, Muhammad Ahmed Ilyas, Jaghat Ram, Ejaz Ul Haq, Zaryab Ahmed Khuwaja, Gohar Riaz, Ahmed Raheem
Objectives: This updated meta-analysis aimed to consolidate clinical evidence comparing the clinical outcomes of intravascular ultrasound (IVUS)-guided LMCA stenting versus conventional angiography-guided LMCA stenting. Methodology: We included “randomized controlled trials” and “observational studies” published in peer-reviewed English language journals that compared the clinical outcomes of LMCA revascularization using “drug-eluting stents (DES)” via “IVUS-guided” versus “angiography-guided” stenting. The primary outcome of interest was “major adverse cardiovascular events (MACE)”, while secondary outcome variables included “all-cause mortality”, “myocardial infarction (MI)”, “target vessel/lesion revascularization (TVR/TLR)”, and “stent thrombosis (ST)”. Risk ratios (RRs) for each outcome variable were calculated using the “Mantel-Haenszel method”. Results: The analysis included nine studies involving a total of 5,344 patients, with 2,282 undergoing “IVUS-guided” LMCA stenting and 3,062 undergoing “angiography-guided” LMCA stenting. “IVUS-guided” LMCA stenting showed a significant reduction in the risk of MACE compared to “angiography-guided” LMCA stenting, with a RR of 0.46 [95% CI: 0.27 - 0.79]. However, a high level of heterogeneity (I2=94%; p<0.01) was observed among the included studies. Additionally, “IVUS-guided” LMCA stenting was associated with significant reductions in all-cause mortality, MI, and ST, with RRs of 0.38 [0.21 - 0.66], 0.45 [0.26 - 0.77], and 0.24 [0.10 - 0.57], respectively. There was no statistically significant difference in TVR/TLR between “IVUS-guided” and “angiography-guided” LMCA stenting, with an RR of 0.64 [0.27 - 1.51]. Conclusion: “IVUS-guided” LMCA revascularization using DES was associated with a lower risk of MACE, death, MI, and ST compared to conventional “angiography-guided” LMCA stenting.
{"title":"An Updated Meta-Analysis of Clinical Trials and Observational Studies of Intravascular Ultrasound- versus Angiography-guided Left Main Stenting","authors":"Nimra Ashraf, Muhammad Ahmed Ilyas, Jaghat Ram, Ejaz Ul Haq, Zaryab Ahmed Khuwaja, Gohar Riaz, Ahmed Raheem","doi":"10.47144/phj.v56i3.2596","DOIUrl":"https://doi.org/10.47144/phj.v56i3.2596","url":null,"abstract":"Objectives: This updated meta-analysis aimed to consolidate clinical evidence comparing the clinical outcomes of intravascular ultrasound (IVUS)-guided LMCA stenting versus conventional angiography-guided LMCA stenting. Methodology: We included “randomized controlled trials” and “observational studies” published in peer-reviewed English language journals that compared the clinical outcomes of LMCA revascularization using “drug-eluting stents (DES)” via “IVUS-guided” versus “angiography-guided” stenting. The primary outcome of interest was “major adverse cardiovascular events (MACE)”, while secondary outcome variables included “all-cause mortality”, “myocardial infarction (MI)”, “target vessel/lesion revascularization (TVR/TLR)”, and “stent thrombosis (ST)”. Risk ratios (RRs) for each outcome variable were calculated using the “Mantel-Haenszel method”. Results: The analysis included nine studies involving a total of 5,344 patients, with 2,282 undergoing “IVUS-guided” LMCA stenting and 3,062 undergoing “angiography-guided” LMCA stenting. “IVUS-guided” LMCA stenting showed a significant reduction in the risk of MACE compared to “angiography-guided” LMCA stenting, with a RR of 0.46 [95% CI: 0.27 - 0.79]. However, a high level of heterogeneity (I2=94%; p<0.01) was observed among the included studies. Additionally, “IVUS-guided” LMCA stenting was associated with significant reductions in all-cause mortality, MI, and ST, with RRs of 0.38 [0.21 - 0.66], 0.45 [0.26 - 0.77], and 0.24 [0.10 - 0.57], respectively. There was no statistically significant difference in TVR/TLR between “IVUS-guided” and “angiography-guided” LMCA stenting, with an RR of 0.64 [0.27 - 1.51]. Conclusion: “IVUS-guided” LMCA revascularization using DES was associated with a lower risk of MACE, death, MI, and ST compared to conventional “angiography-guided” LMCA stenting.","PeriodicalId":42273,"journal":{"name":"Pakistan Heart Journal","volume":"25 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136343745","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The trans-radial approach (TRA) is shown to be superior in reducing bleeding complications and associated with lower mortality with a similar procedural success rate in ST-Elevated Myocardial Infarction (STEMI) patients compared to the trans-femoral approach. Nevertheless, complications such as forearm hematoma and, in rare cases, acute compartment syndrome (ACS) may develop, thus requiring a prompt surgical procedure. Here, we present two successful emergency fasciotomy cases as ACS treatment following primary percutaneous coronary intervention after STEMI. Both patients show normal neurological and muscular function and normal artery flow on both hands afterward.
{"title":"Forearm Compartment Syndrome due to Transradial PCI in STEMI: Case Series of What Can Go Wrong and Lesson Learned","authors":"Rismarini Asanti, Sidhi Laksono","doi":"10.47144/phj.v56i3.2599","DOIUrl":"https://doi.org/10.47144/phj.v56i3.2599","url":null,"abstract":"The trans-radial approach (TRA) is shown to be superior in reducing bleeding complications and associated with lower mortality with a similar procedural success rate in ST-Elevated Myocardial Infarction (STEMI) patients compared to the trans-femoral approach. Nevertheless, complications such as forearm hematoma and, in rare cases, acute compartment syndrome (ACS) may develop, thus requiring a prompt surgical procedure. Here, we present two successful emergency fasciotomy cases as ACS treatment following primary percutaneous coronary intervention after STEMI. Both patients show normal neurological and muscular function and normal artery flow on both hands afterward.","PeriodicalId":42273,"journal":{"name":"Pakistan Heart Journal","volume":"68 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136342898","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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