Browsing by Author "Dali, B"
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Publication Acute coronary syndrome and cardiac biomarkers(Institute of Medicine, 2015) Dali, BAbstract Introduction: Diagnosis of acute cardiac event in the early stage of its onset is of utmost important in the treatment process whereas the development of highly sensitive and specific immunoassays for myocardial proteins such as cardiac Troponin I (cTnI) had made it possible. Given the possible complexities in establishing an early and accurate diagnosis of acute coronary syndrome (ACS), it is important for the clinician to use all available information, including the history, physical exam (PE), electrocardiogram (ECG), and cardiac biomarkers to formulate both the diagnosis of Acute coronary syndrome (ACS) and the overall assessment of patient prognosis and risk. Hence, the study was carried out to assess the clinical profiles of acute coronary syndromes and compare it with cardiac biochemical markers in Acute coronary syndrome (ACS) patients. Methods: Hundred and eight consecutive cases of acute coronary syndrome (ACS), attending the Coronary Care Unit (CCU), of Tribhuvan University Teaching Hospital fulfilling the study criteria were taken for the present study. A record of physical findings was made and cardiovascular examination was done in each case. All the cases were scrutinized to a detail serial 12 lead electrocardiogram (ECG), serial cardiac biochemical markers- Troponin I (cTnI), Lactate dehydrogenase (LDH), aspartate transaminase (Serum Glutamate Oxaloacetate Transaminase, SGOT), and Creatine Kinase Myocardial Band (CK-MB), chest x-ray and laboratory test(e.g. Lipid profile, blood sugar), and echocardiographic study. Results: Acute coronary syndrome was found to be more common in males (51%) than in females (49%). Ages ranged from 30 to 80 years. The common clinical presentations were chest pain (79%), palpitation (74%), sweating (71%), vomiting (45%), acute pulmonary oedema (6%), cardiac arrest (.9%) and (7%) presented with syncope. CKMB were high in about (64%), whereas troponin positive cases were (60%). (89%) presented with abnormal ECG findings, STEMI was diagnosed in (33%), NSTEMI in (29%), whereas (40%) was found to have UA. Main clinical profiles were diabetes (35%), hypertension (76%), and hyperlipidemia (61%), smoking (78%), alcoholic (47%) and family history of cad (57%), overweight (25%) while obesity (36%) and abnormal WHR (69%) respectively. There was significant correlation between clinical profiles and ECG, Creatine Kinase Myocardial Band (ck_mb), troponin and types of ACS, but a slight negative correlation was detected in profiles for WHR and troponin, and fasting hyperglycemia, education, gender, diabetes, hypertension, smoking, Chest pain, heart rate, WHR, and low HDL profile with types of ACS. Conclusion: The outcome of this study showed that the majority are male, relatively younger as compared to Western population, have smoking and hypertension followed by diabetes as the major risk factors. USA and STEMI are the dominant types of ACS and the majority of patients are likely to have hypertension, IHD and diabetes in their families. Better control of risk factors and the awareness of preventive strategies are needed. Keywords: Acute coronary syndromes, Clinical profile, electrocardiogram, cardiac biomarkersPublication Clinical and Echocardiographic assessment of Patient's with Rheumatic Heart Disease(Institute of Medicine, 2016) Dali, BAbstract Introduction: In developed countries rheumatic heart disease (RHD) have become uncommon health problems. On the contrary, in the developing countries like Nepal they remain the leading cause of heart disease in children and young adults augmenting morbidity and mortality. The prevalence of RHD varies considerably through the world. The global average prevalence rate of RHD was 2.2/1000 ranging between 0.1 and 12.6 according to World Health Organization (WHO). Community based data are not available regarding the prevalence and distribution of RHD whereas recent epidemiological data are limited to school surveys and facility based reports. Because of low enrollment rates and frequent absenteeism, these studies are unlikely to reflect accurately the epidemiology of RHD in Nepal. The aims of this study were to analyze the clinical presentation pattern of the involvement of various valves and complication in established RHD. To assess the accuracy of clinical evaluation of valvular heart disease to compare it with echocardiographic evaluation. Methods: Fifty consecutives cases of RHD, attending the outpatient department (OPD), of Tribhuvan University Teaching Hospital fulfilling the criteria, formed the material for the present study. Cases were examined in detail with record of physical findings made and cardiovascular examination done in each case. All the cases were scrutinized to detail echocardiographic study using Hitachi EUB 555, 12 lead EKG, chest x-ray and laboratory test. Design of the study was carried out in prospective, cross sectional study. Results: The distributions of the various valvular lesions were noted singly and in combination. Females were more commonly affected 80% than males 20%. Majority of the patient studied had past history of rheumatic fever (72%). Mitral stenosis (MS) was noted in 38 (76%) clinically and 45 (90%) were diagnosed by echo. Pure MS were found in 4 cases (8%). Mitral Regurgitation (MR) was the second most common lesion clinically, in 29 (58%) and 44 (88%) by echocardiography. Keywords: Rheumatic heart disease, Doppler echocardiography, Mitral valvePublication Impact of Elective Abortion in pregnancy with Cardiac problems(Institute of Medicine, 2011) Shrestha, B; Dali, B; Paudel, P; Jha, R; Rana, A; Gurung, G; Baral, GAbstract Introduction: Pregnant women with heart diseases advance either to preterm/term delivery. Some of the pregnancies end in abortions, which however are spontaneous or are terminated for medical reasons. Method: Retrospective study done in the Department of Obstetrics and Gynecology at Tribhuvan University Teaching Hospital from April 2010 to March 2011 (Baisakh 2067 to Chaitra 2067); Source of data was Operation Theater Register and Admission files. Results: MTP were done for altogether 18 cases of heart diseasesin pregnancy. Primigravida (6) and multigravida (12) were seen in age groups 20-30 (13); 30-40 (5) at gestational weeks of 6-8 (n=10); 9-10 (n=6); 11-12 (n=1); >12 (n=1). The heart diseases were {CHD (1); rest 17 RHD: Majority being done following post valve replacement surgery 11[AVR (1); DVR (3) & MVR (7)]}. Latter mandated a tedious process of anticoagulation, switching from heparin to warfarin and vice versa demanding prolonged hospitalization (up to 12 days) as co- morbidity. Mainly because repeat MVA was needed for incomplete abortion as complication in one case, subsequent procedures were done under USG guidance. Conclusion: It is simpler and safer to avoid pregnancy in heart diseases; especially in those women with post valve replacement surgery rather than imposing MTP, the procedure concerned are not without associated risk, beyond doubt. Keywords: Medical termination of pregnancy (MTP), anticoagulation, valve replacement surgeryPublication Maternal cardiac diseases complicating pregnancy: a review of 105 cases(Institute of Medicine, 2001) Rana, A; Singh, M; Manandhar, B; Pradhan, N; Gurung, G; Dali, B; Koirala, B; Koirala, RRAbstract The outcome of pregnancies in 105 patients with heart diseases in TUTH, Kathmandu, Nepal between April 1995 and May 2001 was reviewed. The incidence of heart disease was 0.55% of the total 19038 deliveries. Rheumatic (79), congenital (17) and miscellaneous groups (9) complicated the pregnancy. Significant number (53) had their diagnosis made at the index pregnancy. Patients who developed cardiac failure (17) mostly did during antenatal period (20-42 weeks); the majority had cardiac failure (14) at third trimester. Two of the cases that had cardiac failure at 33 weeks ultimately had stillbirths later at term. Induction of labour for such cases, which was discouraged earlier, should be considered. In our hospital labour analgesia with epidural anaesthesia, pethidine or morphine is not a routine practice. Injection Methergin is also generally withheld. Save one or two, most Cesaerean sections had obstetrical indication. Prophylactic forceps or ventouse were barely used. There were two maternal deaths. One of them had pregnancy complication as eclampsia and presented with SVT and MI at 34 weeks. The other case died within 48 hours of Caesarean delivery for critical mitral stenosis with pulmonary hypertension. The perinatal losses were 7. This article strongly emphasizes the need for routine cardiac evaluation of patients at their very first antenatal check up so that patie nts with cardiac disease can benefit from shared co-operation between cardiologist, cardiothoracic surgeon, anaesthelogist and obstetrician. Keywords: Heart disease, pregnancy, cardiac failure, obstretic analgesia, induction of labourPublication Maternal Mortality in Pregnancy with Heart Disease(Institute of Medicine, 2014) Dali, B; Baral, JAbstract Introduction: The incidence of heart disease complicating pregnancy is approximately 1–3% of pregnancies and is responsible for 10 to 15% of maternal mortality. While rheumatic heart disease is on real decline in western world, it is adamantly remaining unchanged here in Nepal and persistently contributing to maternal mortality in cardiac complication in pregnancy. Methods: From the ongoing maternal mortality study since BS 2050 (13th April 1993), data from last 15 years (April 1998 - 2013) were extracted. The data were tabulated and analyzed. Results: There were 14 12.5% deaths accountable to heart disease in a total 112 maternal mortality during the period of 15 years and they were mostly from rheumatic heart disease. Most of them were multivalvular heart disease except for a solitary case of aortic stenosis. MTP (2) Caesarian (3) breech vaginal delivery (1) were performed and spontaneous expulsion was managed along with supportive care delivered in mothers who died shortly after admission. Conclusion: Poor health seeking behavior and careless attitude is a part of blame game played often played whereas mortality from rheumatic heart disease which is obsolete in global scenario is of utmost concern as cardiac conditions pertaining to this etiology can be minimized certainly and the mortality attributed thus can be reduced. Termination of pregnancy should only be allowed for reason more than valvular lesion like coarctation of aorta. Keywords: Heart Disease, maternal mortalityPublication Problems faced in the surgical management of rheumatic heart disease in Nepal(Institute of Medicine, 2000) Shrestha, BM Singh; Joshi, PR; Dali, B; Timila, R; Shrestha, UK; Marahatta, MN; Koirala, B; Sharma, GP; Bhatta, MAbstract Rheumatic heart disease (RHD) is a very common cardiac disease in Nepal. The public awareness among Nepalese population is negligible, therefore it is seen in very early age and in severe form. The majority of the patients are of low socio-economical condition, who cannot afford expensive valve replacement surgery. All these facts create a daunting problem in the surgical management of the disease for the newly established open heart surgery unit. The first regular open heart surgery in Nepal was started on 20 February 1997 in Tribhuvan University teaching Hospital (TUTH), Kathmandu. Closed heart surgery was the only procedure available for isolated mitral stenosis in the past. Since 1997 in three years, a total of 285 cases of RHD were referred for surgery. Male to female ratio was 1.1:1.0. The youngest patient was 3 years and oldest 58 years with a mean age of 30 years. There were 32 patients (11%) under the age of 16 years. The isolated mitral valve disease was found in 195 cases (68%), aortic valve disease in 28 cases (10%) and double valve disease in 62 cases (22%). In the mitral valve disease, severe subvalvular fusion and calcification were found in 101 (52%) and 76 patients (39%) respectively, whereas closed mitral commissurotomy (CMC) was possible in only 69 patients (35%). In 3 years, 104 cases of valve surgeries were performed at TUTH. CMC was perfomed in 55 cases whereas open heart surgery in 49 cases of RHD patients. Here we present our difficulties in beginning regular open heart surgery in Nepal and the problems faced by our patients. Keywords: Rheumatic heart disease, open heart surgery, Nepal