Rawalpindi Institute of Cardiology starts Acute Stroke Intervention Service

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 19th Annual Cardiology Update Symposium by PIMS

Rawalpindi Institute of Cardiology starts
Acute Stroke Intervention Service

It is a game changer in stroke management with dramatic results
which prevents premature disabilities-Gen. Azhar Mahmood Kayani

RIC now plans to train interventional cardiologists
and interventionists from all the specialties

ISLAMABAD: Rawalpindi Institute of Cardiology has become the first center in the country to start Acute Stroke Intervention Service. RIC is already providing state of the art interventional cardiology services and it the only cardiac healthcare facility in the province of Punjab in the public sector which is also offering primary PCI facilities round the clock. Credit for establishing this most modern state of the art cardiac centre of course goes to the Provincial Government of Punjab which under the dynamic leadership of former Chief Minister Mian Shahbaz Sharif had provided this gift to the people of Rawalpindi-Islamabad. Maj. Gen. (Retd) Azhar Mahmood Kayani a renowned interventional cardiologist was appointed its Executive Director who managed to build a team which includes highly talented experienced interventional cardiologists, neurologists, radiologists and other support staff who are doing a commendable job. Initial results of this Acute Stroke Intervention Service were presented at the recently held Cardiology Update symposium held at Bhurban on June 30th 2018 by Dr. Asim Javed which earned RIC and its team lot of appreciation.


Maj. Gen. (R) Azhar Mahmood Kayani
Executive Director RIC

Major Gen. Azhar Mahmood Kayani believes that Acute Stroke Intervention is a game changer in the management of stroke with dramatic results which prevents premature disabilities. RIC, he says, has taken this initiative to start acute stroke intervention service and this facility is being provided free of charge. Interventional cardiology in Pakistan, he says, has the infrastructure with all the facilities of skilled manpower, functional Cath labs, CT scan and they need to play an active role in training and then performing stroke interventions. This is the need of the hour and RIC is providing this facility to non-affording patients free of cost. We plan to train all interventional cardiologists and interventionists from all the specialties so that this service is made available 24/7 similar to primary PCI for STEMI. He believes that all concerned specialties need to join hands and start this service as soon as possible. The initiative taken by RIC, Maj. Gen. Kayani believes will motivate other well established cardiology centers to start this service. We need to move at a fast pace to reduce morbidity and mortality from stroke thus saving people from lifelong disability.


Presenting the cardiologists experience of acute stroke intervention at the Cardiology Update symposium held at Bhurban on June 30th, Dr. Asim Javed shared their initial results. Stroke disability, he pointed out, is worse than death. About one third stroke patients die, another one third have permanent, moderate to severe disability while the remaining one third have mild disability or recover completely. Today stroke can be reversed. For this acute stroke intervention service, cardiologists, neurologists and radiologists have to come together and work as a team. Before starting this service at RIC, we had hands on animal lab experience in Malaysia and then training in comprehensive stroke center in United States at Neuro intervention department of West Virginia University Hospital. Dr. Sarmad Ishtiaq has joined us as consultant neurologist and we have signed an MOU with DHQ Hospital Rawalpindi for neurosurgical back up.


Dr. Asim Javed

We have prepared our own stroke pathways based on 2018 AHA/ASA acute stroke management guidelines and data collection audit forms. It was on April 13th 2018 that Rawalpindi Institute of Cardiology became the first center in Pakistan to perform acute stroke intervention and reverse patient’s paralysis. We are now performing acute stroke interventions regularly with excellent procedural and clinical outcomes. We have also provided cardiac and stroke rehabilitation services. We are now prepared to train people in acute stroke intervention at any other institution as well. We are collecting the data with risk factors to audit our services. He then showed a few cases which they had managed using stents getting dramatic and immediate response with stroke intervention. We all must join hands and start this service immediately all over the country he added.


Participating in the discussion Maj. Gen. Azhar Mahmod Kayani said that if you want to do something just do it. That is the way to work in Pakistan. Once you are convinced that it is in the interest of the patient, just go ahead and do it and do not ask anyone. This is the requirement of the patient. Since there are no rehabilitation services, stroke patients suffer throughout their life. Acute Stroke Intervention has over 70% success rate. What we need to do is train our people, let us join together and makeit a multidisciplinary team and start working. It is important to stabilize the airway and breathing immediately after the procedure, he added.


Dr. Akhtar Ali Bandeshah
Convener of the symposium

Dr. Umair Rashid Chaudhry from Lahore speaking on the current Status and the way to Go for acute stroke intervention service said that anyone who is a good angiographer can do it. Acute center is the Cath Lab. Stroke is a different unit in the developed world and it is run and managed by neurologists. Neuro anatomy is very simple. He then discussed in detail the neuro imagings, CT, CTA, MRI, MRV and DSA. Time, he stated, is brain. Awareness among the healthcare professionals is extremely important. He then talked about Throbectomy for stroke, described in detail the sucking and plugging techniques. The aim, he said, should be to save the patient and not impress others for felicitations. He agreed that neuro interventions were a bit difficult and it has a 55% success rate. If there are malignant infarct lesions, do not treat it.

A highly informative colourful brochure on Acute Stroke Intervention- beginning of a new era of stroke cardiologist prepared by Rawalpindi Institute of Cardiology was also distributed among the participants. According to the information it contains, almost 87% of brain strokes are caused by ischemia, 38% of these ischemic strokes are caused by Large Vessel Occlusions (LVO) which if left untreated cause major disabilities. Acute stroke intervention is now the standard of care for acute ischemic stroke with 80% recanalization success with acute stroke intervention. Almost 70% of the patients achieve minimal disability at the end of ninety days after the procedure or recover completely. Acute stroke intervention is carried out on ischemic Large Vessel Occlusions. Interventional cardiologists are already providing acute stroke intervention service in South Africa, Czech Republic, Turkey, United States of America, Germany, Netherlands, Slovakia and Portugal. This brochure gives detailed acute stroke pathways, detailed pictorial coverage of management of four acute stroke interventions with dramatic results. Important members of this Acute Stroke Intervention team include rehabilitation physician, cardiologist, neurologist or strokologist, radiologist and neurosurgeon.


This session was chaired by Maj. Gen. Azhar Mahmod Kayani along with Prof.Azhar M.A. Farooqui, Dr.Bashir Hanif and Prof. Khalida Soomro. Dr. Bilal Mohyuddin was the moderator of this session. Dr. Nadir Khan talked about development of CTO-PCI procedures and showed some interesting cases of proximal LAD CTO. Brig. Afsar Raza discussed problems and possible solutions in coronary calcific lesions. Coronary calcification, he said, is a risk factor with adverse outcome of CAD. Diabetics with kidney disease are treated with CCBs, estrogen. He also discussed the different interventional procedures in detail and presented the results of PCI and stenting, cutting balloons, athrectomy. Rigid calcification, he pointed out, still remains a great challenge. Dr.Suhail Aziz made a presentation on LMS PCI, Tips and Tricks. Left main stem, he stated, has remained a no go area for cardiologists. It is a difficult vessel to treat and we need tailor made treatment plan for all patients. He then showed Video of a few procedures.


Dr. Bilal S.Mohydin (extreme left) moderating the session during the Cardiology Update seminar held
at Bhurban recently. Also sitting on the dais are Dr. Bashir Hanif, Maj. Azhar M. Kayani and others.

Dr. Qamar Aziz Rana talked about athrectomy devices and gave an appraisal of the current techniques. He pointed out that they use these devices in less than 5% of the PCI patients. He also talked about Rota ablation, Rotablater system, its indications, under expanded stents, laser treatment besides discussing orbital athrectomy. Dr. Miqdad Khan spoke about stent fractures and said that it is seen in 12.3% of patients with metallic stents. Overall the stent fracture is reported to be 22% but if you have not seen it, either you are not looking at it or you are missing it. Stent fracture, he said, is always there. He then highlighted the predictors of stent fracture and its consequences. Instant restenosis is very important and stent fracture is more common than we think, he remarked.

This was followed by another excellent presentation on Peripheral Vascular Interventions by Prof. Amber Malik from Shaikh Zayed Hospital Lahore. She first described the spectrum of PAD, showed some slides with almost half eaten feet. Mortality from PADS is about 30%. Patients suffering from diabetes, hypertension who are smokers suffer more from gangrene and sometimes death. We need to work on limb salvage and reduce mortality. It needs a team work wherein vascular surgeon, orthopaedic surgeon, cardiologists and Diabetologists all play a very important role. She also referred to the ESC Guidelines for PAD, talked about limb threatening ischemia. People usually avoid doing vascular surgery and at present there is very little work going on in vascular surgery in the country. We now manage about seventy PAD patients every year and do about forty venoplasties. Multimodality units are needed for the management of these cases. She then discussed the management of four cases and pointed out that these are no go areas for the surgeons. One of the elderly ladies who was saved from amputation, she said, was extremely grateful. At times we do get a death on table consent from the patient before performing these procedures.

Dr. Aurangzeb Khan talked about LMS stenting, described different techniques and their long term outcome. These intervention procedures cost, he opined, must be borne by the community. Friends of PIC at Lahore have done a lot in this respect. He also showed the management of a number of cases of LMS stenting. During the discussion it was stated that one should not stick to one technique, change it if need be.


Prof. Azhar M.A. Faruqui along with other members of the experts panel chairing one
of the scientific sessions during the Cardiology Update Seminar held recently.

Summing up the session Maj. Gen. Azhar Mahmod Kayani said that we need to build multidisciplinary teams in our centers. We have managed to do that at Rawalpindi Institute of Cardiology. We have our own consultant neurologist, signed an MOU with another hospital for neurosurgical back up. Head of the institutions has to manage everything within the given budget. We have done it at RIC. One must know how to run and manage a hospital efficiently. When we started I was the only interventional cardiologist but now we have a twelve members PCI team and offer 24/7 primary PCI service. We are doing all this with no extra budget. It is doable but you have to prioritize it. Now we can train others in acute stroke intervention. Dr. Bashir Haneef said that It is extremely important to have well trained human resource and basic infrastructure. Prof. Azhar MA Farooqui opined that it was amazing to see the cardiologists doing all these procedures and it is amazing what we are able to do now. We need some wisdom, slow down, think what is appropriate for Pakistan. It is expensive but these services are needed. We should be doing cost effective procedures in Pakistan.

Panel Discussion

During the panel discussion it was pointed out that in LAD lesions do not do any interventional procedures if you are not experienced enough. CABG by experienced surgeons offers 10-15 years good quality of life. It is always better to discuss risk benefits with the family in counseling sessions. Cardiologists do send patients to cardiac surgeons for opinion. They advice the surgeon and if the stenting is good, they should tell the patient as well. It was also pointed out that since there is lot of money involved, at times the opinion by the heart team is biased. For triple vessel disease CABG is the gold standard. Dr. Suhail Aziz remarked that the field of interventional cardiology is pushing its boundaries but we should be careful not to harm the patient. Majority of the Left Main Disease patients are candidates for surgery. PCI in these patients could be risky. It is essential that one should discuss with the patient before embarking on interventional procedures. One of the participants stated that in triple vessel disease, one can put four to five stents and have good outcome. All symptomatic patients should be referred for PCI. If the patient has good LV function send him for PCI and if the left main disease is stable, send it to cardiac surgeon and get their opinion.


Participating in the discussion Prof. Abid Farooqui consultant rheumatologist remarked that when he had angina, he consulted late Dr. Shahid Malik and he immediately referred me to cardiac surgeon. If vessels are not stable the patient should be sent to the cardiac surgeon. Later I had cardiac surgery at Rawalpindi Institute of Cardiology which is a facility that can be compared with any good cardiac center in the world. It was also stated that we need a more organized system. Sometimes the patients do not want cardiac surgery and they will go on consulting the cardiologists till they get the advice they like. For cardiologists it is important that they should tell the patient what is more beneficial for them. Col. Nadir opined that choice of the patient should be mentioned. We do some procedures which are scientifically right. It is important to follow the Heart Team approach. Beating heart surgery is important for any training programme and it is essential that this facility should be available at teaching hospitals.

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