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    Pre-Hospital Delay and Factors Associated With Delayed Presentation Among Patients With ST-Segment Elevation Myocardial Infarction in Peshawar: A Cross-Sectional Study
    (Pakistan Heart Journal, 2026-09-26) Iftekhar, Malik Faisal; Khan, Mansoor Ali Yazdan; Saddique, Uzma
    Objectives: To determine the frequency of pre-hospital delay and identify factors independently associated with delayed presentation among patients with ST-segment elevation myocardial infarction (STEMI) presenting to a tertiary cardiac care center in Peshawar, Pakistan. Methodology: This analytical cross-sectional study included a total of 255 consecutive adults with confirmed STEMI. Data were collected using a structured, pilot-tested pro forma covering sociodemographic characteristics, symptom interpretation, healthcare-seeking behavior, first medical contact, geographic distance, and symptom-onset-to-Coronary Care Unit (CCU)-arrival time. Pre-hospital delay was operationally defined as a symptom-onset-to-CCU-arrival interval >6 hours; this composite interval could include both patient-related and healthcare-system/referral-related components. Results: The mean age of the 255 participants was 59.93 ± 10.57 years, and 133 (52.2%) were female. The median symptom-onset-to-CCU-arrival time was 5.0 hours (IQR: 2.5–9.5), and 123 (48.2%) participants presented >6 hours after symptom onset. After multivariable adjustment, increasing age was associated with greater odds of delay (aOR=1.19 per year; 95% CI: 1.12–1.27; p<0.001), whereas male gender was associated with substantially lower odds compared with female gender (aOR=0.03; 95% CI: 0.01–0.10; p<0.001). Musculoskeletal rather than gastrointestinal symptom misinterpretation (aOR=8.42; 95% CI: 2.94–24.10; p<0.001), misguided healthcare-seeking behavior (aOR=11.18; 95% CI: 4.46–28.02; p<0.001), and first medical contact with a local hospital rather than a cardiac care center (aOR=14.67; 95% CI: 5.42–39.69; p<0.001) were associated with greater odds of delayed presentation. Intermediate versus remote distance was associated with lower odds of delay (aOR=0.09; 95% CI: 0.03–0.27; p<0.001). Educational level, urban/rural residence, economic status, and proximate versus remote distance were not independently associated with delay. Conclusion: Nearly half of the patients with STEMI presented to definitive cardiac care more than six hours after symptom onset. Delayed presentation was associated with older age, female gender, musculoskeletal symptom misinterpretation, misguided healthcare-seeking behavior, and initial contact with a local non-cardiac facility.
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    A Rare Case of Dual Syncope, Vagal and Psychogenic Mechanism, Elucidated by a Head-Up Tilt Test (HUTT)
    (Pakistan Heart Journal, 2026-09-25) Hyder, Habiba Ghulam; Khan, Shahtaj; Saeed, Zainab; Soomro, Ghulam Hussayn; Mujtaba, Mustajab; Khan, Aamir Hameed
    A 51-year-old woman, with congenital inability to hear and speak, came with recurrent episodes of syncope. The syncope was unheralded (without warning) on most occasions. It was not associated with nausea, vomiting, cold sweats. It was sudden in onset and was often triggered by emotional stress. There was a history of the recent demise of three siblings in short succession. The syncope was in the upright as well as while supine positions. The examination was unremarkable with a normal orthostatic response. All basic laboratory investigations were normal. The electrocardiogram showed partial right bundle branch block while the echocardiogram revealed a normally functioning heart. Head-up tilt testing revealed two episodes of syncope in the same test, with the first syncope during the plain tilt with normal blood pressure and heart rate and spontaneous recovery, while tilt was continued at 70 degrees. The second syncope occurred with nitrate provocation, with typical neurocardiogenic response (predominantly vasodilatory). The patient became incontinent for urine and experienced myoclonic jerks. The diagnosis of psychogenic pseudosyncope and neurocardiogenic syncope was confirmed on the tilt test.
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    Perioperative Outcomes and Factors Associated with Adverse Events in Neurosurgical Patients with Significant Cardiac Comorbidities: A Prospective Observational Cohort Study
    (Pakistan Heart Journal, 2026-09-25) Sultan, Amina; Naz, Lubna; Rahim, Rahida; Urooj, Sundus; Mabood, Shahid
    Objectives: Neurosurgical patients with established cardiac comorbidities represent a clinically vulnerable population because major neurosurgical procedures impose substantial cardiovascular and physiological stress while requiring careful maintenance of cerebral perfusion and systemic haemodynamic stability. This study aimed to determine the frequency and pattern of adverse perioperative outcomes and to explore clinical and perioperative factors associated with adverse events among neurosurgical patients with significant cardiac comorbidities. Methodology: This prospective observational cohort study included consecutive adults with established significant cardiac comorbidities undergoing major neurosurgical procedures. Participants were followed from the index operation through hospital discharge, with vital status reassessed 30 days after surgery. The prespecified primary outcome was the occurrence of at least one adverse perioperative event during the index hospitalization. Secondary outcomes included study-defined major adverse cardiac events (MACE), individual cardiac, neurological, respiratory and renal complications, critical-care utilization, length of hospital stay, and mortality. Results: A total of 200 participants were analyzed; mean age was 59.0 ± 11.7 years, and 120 (60.0%) were male. At least one adverse perioperative event occurred in 113 participants (56.5%; 95% CI 49.6–63.2), while 40 (20.0%; 95% CI 15.0–26.1) experienced study-defined MACE. Myocardial injury occurred in 44 (22.0%), perioperative myocardial infarction in 11 (5.5%), acute heart failure in 25 (12.5%), treated postoperative arrhythmia in 25 (12.5%), prolonged ventilation >24 hours in 68 (34.0%), and neurological deterioration in 25 (12.5%). In-hospital mortality was 4.0%, and 30-day mortality was 7.0%. In multivariable analysis, emergency surgery was associated with substantially higher odds of the composite adverse outcome (adjusted OR 17.74; 95% CI 5.44–57.83; p<0.001), as were ASA physical-status class IV–V (adjusted OR 7.70; 95% CI 1.47–40.27; p=0.016) and increasing age per 10 years (adjusted OR 1.41; 95% CI 1.02–1.95; p=0.038). Conclusion: Neurosurgical patients with established cardiac comorbidities experienced a substantial burden of perioperative adverse events, with more than half experiencing at least one component of the prespecified composite outcome and one-fifth experiencing study-defined MACE. Emergency surgery, advanced ASA physical status, and increasing age were associated with higher adjusted odds of adverse perioperative outcomes.
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    Left Atrial Appendage Emptying Velocity and Coexisting Echocardiographic Findings in Severe Rheumatic Mitral Stenosis: A Single-Centre Cross-Sectional Observational Study
    (Pakistan Heart Journal, 2026-09-25) Khalid, Salman; Abid, Muhammad Shuaib; Sajid, Usman; Ali, Amjad
    Objectives: To describe the distribution of left atrial appendage emptying velocity (LAAEV) and the coexistence of atrial fibrillation (AF), spontaneous echo contrast (SEC), and left atrial appendage (LAA) thrombus among patients with severe rheumatic mitral stenosis undergoing transoesophageal echocardiography (TEE). Methodology: This single-centre, cross-sectional observational study included 50 consecutive adults with severe rheumatic mitral stenosis who underwent clinically indicated TEE at the Department of Cardiology, Punjab Institute of Cardiology, Lahore, Pakistan, between 21 May and 31 July 2026. Severe rheumatic mitral stenosis was defined by characteristic rheumatic valve morphology and a mitral valve area ≤1.5 cm² measured using two-dimensional echocardiographic planimetry. LAAEV was assessed using pulsed-wave Doppler and categorized a priori as <20, 20–29, 30–39, and ≥40 cm/s for descriptive purposes. AF, SEC, and LAA thrombus were also recorded. Results: The mean age of participants was 37.3 ± 9.4 years; 45 (90%) were female, and the mean mitral valve area was 1.01 ± 0.22 cm². LAAEV was <20 cm/s in 18 patients (36%; 95% CI: 22.9–50.8%), 20–29 cm/s in 11 (22%; 95% CI: 11.5–36.0%), and 30–39 cm/s in 21 (42%; 95% CI: 28.2–56.8%); no participant had an LAAEV ≥40 cm/s. Overall, 29 patients (58%; 95% CI: 43.2–71.8%) had LAAEV <30 cm/s. AF was present in 29 patients (58%; 95% CI: 43.2–71.8%), SEC in 32 (64%; 95% CI: 49.2–77.1%), and LAA thrombus in 15 (30%; 95% CI: 17.9–44.6%). Conclusion: Lower predefined LAAEV categories were frequently observed in this cohort of patients with severe rheumatic mitral stenosis, alongside substantial frequencies of AF, SEC, and LAA thrombus. These findings are descriptive and do not establish statistical association, prediction, causality, or prognostic utility. Larger prospective studies retaining continuous patient-level LAAEV measurements and longitudinal thromboembolic outcomes are warranted.
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    Obesity and Chest Pain Presentation among Yemeni Adults with Angina and Nonobstructive Coronary Arteries: A Cross-Sectional Study
    (Pakistan Heart Journal, 2026-09-23) Al-Jalal, Abdulmalek; Al-Kebsi, Mohammed M.; Nono, Osama Al; Al-Motarreb, Ahmed; Al-Namshah, Tasneem; Al-Odhari, Rowida; Alkhorasani, Haitham; Jayed, Abdullah
    Objective: To determine whether obesity was associated with chest pain rather than dyspnea-only presentation among Yemeni adults with angina and nonobstructive coronary arteries (ANOCA) and to explore differences in cardiovascular risk factors, laboratory parameters, routine echocardiographic and angiographic findings, and medication exposure according to obesity status. Methodology: This hospital-based cross-sectional study included 151 consecutive Yemeni adults undergoing elective invasive coronary angiography. Eligible participants presented with chest pain or dyspnea considered an angina-equivalent symptom and had either no visible epicardial coronary stenosis or <50% stenosis in all major epicardial vessels. Obesity was defined as body mass index ≥30 kg/m². Seven participants with overlapping chest pain and dyspnea indicators were excluded only from the primary presentation-specific analysis, leaving 144 participants. Results: Of 151 participants, 49 (32.5%) were obese. Among the 144 participants with an unambiguous symptom classification, 108 (75.0%) presented with chest pain and 36 (25.0%) with dyspnea without chest pain. Chest-pain presentation occurred in 38/49 obese participants (77.6%) and 70/95 non-obese participants (73.7%; p=0.612). Obesity was not associated with chest-pain presentation after adjustment for age, sex, diabetes mellitus, and hypertension (aOR 1.21, 95% CI 0.53–2.78; p=0.648). A sensitivity analysis including all 151 participants produced a similar result (aOR 1.11, 95% CI 0.49–2.54; p=0.802). In exploratory analyses, obese participants had higher median LDL-C (120.0 vs 110.5 mg/dL; p=0.007), lower median HDL-C (37.0 vs 42.0 mg/dL; p=0.027), and a greater prevalence of HDL-C <40 mg/dL (55.1% vs 33.3%; p=0.011). Laboratory-defined composite dyslipidemia and routine echocardiographic and angiographic findings did not differ significantly between obesity groups. Conclusions: Obesity was not statistically associated with chest pain rather than dyspnea-only presentation among Yemeni adults with ANOCA. Differences in LDL-C and HDL-C were observed in exploratory analyses but require confirmation.