Effect of Enhanced External Counterpulsation and Cardiac Rehabilitation on Quality of Life, Plasma Nitric Oxide, Endothelin 1 and High Sensitive CRP in Patients With Coronary Artery Disease: A Pilot Study

OBJECTIVE: To investigate the effect of enhanced external counterpulsation (EECP) on plasma nitric oxide (NO), Endothelin 1 (ET1), high sensitive C-reactive protein (HSCRP) and quality of life (QoL) in patients with coronary artery disease (CAD). METHODS: We conducted a pilot randomized clinical trial in order to evaluate plasma NO, ET1, HSCRP and QoL before and after twenty sessions of EECP (group A) and cardiac rehabilitation (CR, group B) in 42 patients with CAD (21 in each group). RESULTS: Forty-two patients (33 male and 9 female) were included in the study. The mean age was 58.2+/-10 years. The mean HSCRP was 1.52+/-0.7 in the EECP group and it was reduced to 1.27+/-0.4 after intervention. The reduction in HSCRP was not statistically significant in EECP and CR groups with p=0.33 and p=0.27, respectively. There was not significant improvement of NO, ET1, and QoL in the EECP and CR groups shortly after therapy (p>0.05). CONCLUSION: Although the short-term EECP treatment in CAD patients improved HSCRP, NO, ET1, and QoL compared with the baseline those improvements are not statistically significant. Further studies are necessary with large study groups and more sessions.

Mitral regurgitation after percutaneous balloon mitral valvotomy in patients with rheumatic mitral stenosis: a single-center study

Percutaneous balloon mitral valvotomy [BMV] is the gold standard treatment for rheumatic mitral stenosis [MS] in that it causes significant changes in mitral valve area [MVA] and improves leaflet mobility. Development of or increase in mitral regurgitation [MR] is common after BMV. This study evaluated MR severity and its changes after BMV in Iranian patients. We prospectively evaluated consecutive patients with severe rheumatic MS undergoing BMV using the Inoue balloon technique between February 2010 and January 2013 in Madani Heart Center, Tabriz, Iran. New York Heart Association [NYHA] functional class and echocardiographic and catheterization data, including MVA, mitral valve mean and peak gradient [MVPG and MVMG], left atrial [LA] pressure, pulmonary artery systolic pressure [PAPs], and MR severity before and after BMV, were evaluated. Totally, 105 patients [80% female] at a mean age of 45.81 +/- 13.37 years were enrolled. NYHA class was significantly improved after BMV: 55.2% of the patients were in NYHA functional class III before BMV compared to 36.2% after the procedure [p value < 0.001] MVA significantly increased [mean area = 0.64 +/- 0.29 cm[2] before BMV vs. 1.90 +/- 0.22 cm2 after BMV; p value < 0.001] and PAPs, LA pressure, MVPG, and MVMG significantly decreased. MR severity did not change in 82 [78.1 %] patients, but it increased in 18 [17.1%] and decreased in 5 [4.8%] patients. Patients with increased MR had a significantly higher calcification score [2.03 +/- 0.53 vs. 1.50 +/- 0.51; p value < 0.001] and lower MVA before BMV [0.81 +/- 0.23 vs. 0.94 +/- 0.18; p value = 0.010]. There were no major complications. In our study, BMV had excellent immediate hemodynamic and clinical results inasmuch as MR severity increased only in some patients and, interestingly, decreased in a few. Our results, underscore BMV efficacy in severe MS. The echocardiographic calcification score was useful for identifying patients likely to have MR development or MR increase after BMV

OPTIMA tacrolimus-eluting stent: a twelve-month clinical follow up with two different periods of dual antiplatelet therapy; 2-monthvs. 6-month approach

There are limited data comparing long-term efficacy and safety of OPTIMA tacrolimus-eluting stent [TES] with Dual Antiplatelet Therapy [DAT] in daily practice. Therefore, we evaluated the safety and performance of OPTIMA TES with 2 or 6-month dual antiplatelet therapy in a 12-month follow up period. In a prospective, non-randomized single center registry in which 106 patients that underwent percutaneous coronary intervention with the OPTIMA TES between January 2010 and February 2011 were enrolled. After stenting, 62 patients received DAT for 2 months and the remainder for 6 months. Major Adverse Cardiac Events [MACE], stent thrombosis rate and target lesion revascularization [TLR] were evaluated in a 12-month follow-up period for 2-and 6-month DAT groups. No cases with death, MI or stent thrombosis were observed within the 12-month follow-up period in either of the groups. TLR and MACE rates were higher in 6-month DAT group compared to 2-month group [6.8% vs. 3.2% respectively, P=0.001] which may be due to this group having more diffuse disease [23.60 +/- 5.69 vs. 20.88 +/- 5.14, P=0.018]. OPTIMA tacrolimus-eluting stent is safe and efficient with short term DAT period. A randomized trial is needed for better evaluations of OPTIMA TES in daily clinical practice.

Outcome of diabetic and non-diabetic patients undergoing successful percutaneous coronary intervention of chronic total occlusion

Diabetes mellitus is associated with an increased risk of adverse clinical outcomes after percutaneous coronary intervention [PCI]. The prognosis of patients with diabetes mellitus and chronic total occlusion [CTO] treated with PCI is poorly investigated. Current study evaluates outcome of successful PCI on CTO in patients with and without diabetes. One hundred and sixty three patients treated with successful PCI on CTO between January 2009 and March 2011 were prospectively identified from the PCI registry at the Madani Heart Center, Tabriz, Iran. Patients were followed for 15 +/- 3 months, were evaluated for the occurrence of major adverse cardiac events [MACE] comprising death, acute myocardial infarction, and need for repeat revascularization. No differences were found in baseline clinical and procedural variables between patients with [n=34] and without diabetes [n=129], unless for hypertension [p=0.03]. Hospitalization period after PCI in diabetics [3.26+0.61 days] and non-diabetics[2.86+0.52 days] was similar. In-hospital MACE occurred in 8 [23.5%] individuals of diabetics and 10 [7.8%]individuals of non-diabetics [p=0.02] among them revascularization was significantly higher in diabetics [20.6% vs. 7%, p=0.04]. Follow-up events in diabetic and non-diabetic groups were 12 [35.3%] and 37 [28.5%], respectively [p was not significant]. In patients undergoing successful PCI on CTO, diabetes is associated with higher in-hospital adverse events; however diabetes does not affect long term outcomes in these patients

twelve-month outcome of biolimus eluting stent with biodegradable polymer compared with an everolimus eluting stent with durable polymer

Drug-eluting stents [DES] have significantly decreased the need for repeat coronary revascularization but concerns remain regarding the safety of first and second generation DES. We compared the safety and efficacy of a biolimus-eluting stent [with biodegradable polymer] with an everolimus-eluting stent [with durable polymer] one We performed a randomized trial to compare the two types of stents. Two hundred patients undergoing PCI for de novo lesions were randomly assigned 1:1 to treatment with either biolimus-eluting [BioMatrix] or everolimus -eluting [Xience V] stent. The primary endpoint was a composite of cardiac death, myocardial infarction, and clinically driven target vessel revascularization within 12 months. Demographics, clinical, and lesion characteristic were comparable between two groups. The 30-day major adverse cardiac event [MACE] rate was 2% in BioMatrix group versus 0% in Xience group [p > 0.05]. After 12 months, the rates of cardiac death [0% in both groups], MI [2% versus 0%, p=0.49] and clinically -driven target vessel revascularization [0% in both groups] were similar for BioMatrix and Xience. No stent thrombosis was reported at 1, 6, 9 or 12 months after intervention in either group. BES [Biolimus-eluting stent] with biodegradable polymer and EES [Everolimus-eluting stent] with durable polymer appear similar with respect to MACE and stent thrombosis in this patient population. Many studies with longer follow up are needed to define better the role of BES with biodegradable polymer in treatment of coronary artery lesions

Cardiac findings in congenital nephrotic syndrome

Congenital nephrotic syndrome is a severe debilitating problem associated with extra renal manifestation such as diverse cardiac findings. During four years 6 cases diagnosed as congenital nephritic syndrome in base of definitive criteria their documents reviewed and echocardiographic evaluation has been done for all with or without cardiac sign or symptoms, results gathered and expressed as incidence. All cases have some grades of structural or functional defects from simple form like as tricus-pid regurgitation to complex defects. It may be run in consecutively in siblings of a family from non consanguine parents. Pulmonary stenosis may occur in all parts subvalvualr, valvular and peripheral parts of pulmonary artery, left ventricular hypertrophy and mitral regurgitation observed in some, moderate tricuspid regurgitation observed in half of cases due to pulmonary hypertension or right ventricular hypertrophy due to pulmonary stenosis

Coronary artery ectasia in a patient with polyeystic kidney disease

A 44 years old male patient with acute coronary syndrome and polycystic kidney disease is described. Coronary angiography showed ectatic coronary arteries. Polycystic kidney disease is the most common inherited kidney disorder which is commonly associated with extra renal manifestations including cardiovascular conditions. Involvement of vessels may lead to arterial aneurysms which most commonly present as intracranial aneurysms. The rare association between coronary aneurysms and polycystic kidney disease has also been noted

impact of stepwise stent deployment on the angiographic and clinical outcome of coronary angioplasty in the setting of an acute myocardial infarction

To detect a reduction in the incidence of no-reflow, and a possible improvement in angiographic and clinical outcome after stepwise stenting in comparison with conventional method in the percutaneous coronary intervention [PCI] of patients with anterior ST elevation myocardial infarction. Between March 2007 and December 2009, patients with anterior acute myocardial infarction [AMI] treated with streptokinase less than 6 hours from presentation who underwent early PCI were enrolled in this multicenter randomized clinical trial. The study was carried out in the Cardiology Departments of Valiasr Hospital of Zanjan, Imam Reza, and Shahid Madani Heart Hospitals, Tabriz, Iran. Four hundred and three patients were enrolled in this study. Patients were randomly divided into 2 groups: Group I [n=202] with stepwise stent deployment [SSD], and Group II [n=201] with routine conventional stent deployment [CSD]. The patients' mean age was 57.7 +/- 10.7 years. After PCI, thrombolysis in myocardial infarction myocardial perfusion grade [TMPG] 0/1, suggestive of no-reflow was significantly higher in CSD group [p=0.0001]. In hospital based, death occurred in 15 patients [7.5%] from CSD group while 4 [2%] from the SSD group [p=0.01]. The TMPG was also significantly higher in SSD group [average 2.32 +/- 0.18] compared with CSD group, [average 1.66 +/- 0.24] [p=0.0001]. Conventional stenting technique was an independent predictor of no-reflow in multivariate logistic regression analysis [hazard ratio - 1.43; 95% confidence interval: 1.15-1.73; p=0.01]. The SSD was associated with improved angiographic reperfusion indices and reduced mortality in early PCI for AMI

One-year outcome of stenting for long coronary lesions, a prospective clinical trial

Background: Percutaneous coronary intervention [PCI] for long coronary lesions is associated with poor angiographic and clinical outcome compared with focal lesions. Here we describe our experience in PCI of such lesions with bare [BMS] or drug eluting stents [DES]. Methods: Between October 2008 and September 2009, One hundred patients with one significant coronary artery stenosis of longer than 20 mm were enrolled in this prospective study. Demographic, clinical and angiographic data were collected and the rate of ischemic events and major adverse cardiac events [MACE] were evaluated in a mean follow up period of about 11.3 +/- 3.2 months. Results: Mean age of participants was 58.08 +/- 8.97 years. Seventy two [72%] patients were male and the remainders were females. Majority of patients underwent DES implantation [25 [25%] BMS, 75 [75%] DES, P<0.001]].There was no difference in frequency of major risk factors distribution among DES or BMS groups. Mean diameter of implanted stent was 2.8 +/- 0.033mm in DES group and 2.9 +/- 0.35 in group with BMS [P=0.214]. The mean length of implanted stent was 25.8 +/- 3.08mm in DES and 23.36 +/- 0.mm in BMS groups [P<0.001]. In-stent restenosis rate was significantly higher in BMS group [6[24%] in BMS and 5[6.9%] in DES, P=0.02]. MACE were observed in 7[9.3%] of patients with DES and 7 [28%] of patients with BMS [P=0.04]. Conclusion: In long coronary lesions implantation of DES was associated with lower MACE compared with BMS in one year follow up. Studies with longer term follow up are needed to further clarify this issue

Association of electrocardiographic changes with severity of coronary artery disease and short term outcome in patients with non-ST-segment elevation acute coronary syndromes

To assess the association between electrocardiogram [ECG] changes in non-ST-segment elevation acute coronary syndrome [NSTE-ACS] patients with severity of coronary artery disease [CAD] and short-term outcome. In this cross-sectional descriptive -analytical study, 111 patients admitted to the Cardiology Department of Shahid Madani Heart Hospital, Tabriz, Iran between March 2005 and March 2007 with first NSTE-ACS, and had undergone coronary angiography during index event were evaluated. One hundred and eleven patients [64 males, and 47 females] were enrolled, and their in-hospital and short-term outcome with a mean follow-up period 4.6 +/- 1.8 months was evaluated. Patients with ST-T changes on admission had higher rates of death [16.7 versus 2.7%, p=0.01], recurrent angina [36.1 versus 6.7%, p=0.001], and pulmonary edema [8.3 versus 1.3%, p=0.045]. The mean left ventricular ejection fraction [LVEF] of patients with ECG changes were significantly lower than those without ECG changes [p=0.001]. Mitral regurgitatio [MR] was also common among those with ECG changes [p=0.006]. In a multivariate regression analysis, the only independent predictor of short-term mortality and adverse clinical event was ST depression on ECG [p=0.001]. In patients with first NSTE-ACS, ST deviation is associated with adverse short-term outcome including more severe CAD, lower LVEF, and more common MR

History of fertility and coronary artery disease in Iranian women older than 50 years old

Coronary artery disease [CAD] is a leading cause of mortality and disability in Iranian population. In this study, the association between parity and the presence of CAD in women more than 50years old age has been investigated in case [100 female patients with documented angiography-defined CAD] and control [320 female subjects with normal echocardiogram] group. Logistic regression analysis revealed that number of pregnancies and hysterectomy with ovarectomy was independent risk factors associated with CAD in this study

Transplanted renal artery stenosis: a case report and review of literature

Transplant renal artery strenosis [TRAS] is a relatively frequent, potentially curable cause of refractory hypertension and allograft dysfunction and usually becomes apparent between 3 months and 2 years after transplantation. Depending on the hemodynamic significance of stenosis it can be treated conservatively or revascularization. Here we describe a case of TRAS which was treated successfully with angioplasty and stenting and then we will have a review on its etiology, natural history, diagnosis and therapy

Porcelain aorta: a case report and a review of literature with especial focus on tuberculosis aortitis

A 36 years old woman with a history of treated pulmonary tuberculosis [TB] was hospitalized fir progressively worsening dyspnea on exertion. She had severe calcification of entire aorta and evidence of old 273 on chest roentgenogram Routine laboratory tests including erythrocyte sedimentation rate [ESR] and C- reactive protein [CRP] were normal and rheumatologic panel was negative. Echocardiography showed severe aortic insufficiency. Work-up for active tuberculosis was negative. The CT scan of the chest was in favor of old tuberculosis and also showed heavily calcified aorta. She underwent aortic valve replacement. Postoperative course was uneventful. At four-year follow up the patient is doing will. Considering her age and the absence of risk factors of atherosclerosis we postulated that porcelain aorta in this patient could be a sequel of remote tuberculosis aortitis

value of endothelium dependent vasodilatation in diagnosing coronary artery disease and its comparison with the results of routine diagnostic tests

To determine the predictive value of flow-mediated vasodilation [FMD] compared with angina pectoris, exercise electrocardiography, and myocardial perfusion imaging [MPI]. This study was carried out in Shahid Madani Heart Center, Tabriz, Iran from April 2004 to September 2006. A total of 92 patients with chest pain syndrome were enrolled in this study. Using high resolution ultrasound system endothelial function was evaluated, and the result of the flow-mediated dilation [FMD%] was defined as the percent change in the internal diameter of the brachial artery during reactive hyperemia related to baseline. Coronary artery disease [CAD] was documented in 77 [83.7%] patients. The percentage of FMD was lower in patients with CAD compared with those without it [3.55 +/- 3.71 versus 10.76 +/- 4.61,P=0.001]. In comparison with typical anginal chest pain [sensitivity 46.7%, specificity 80%], exercise stress test [sensitivity 75%, specificity 60%], and MPI [sensitivity 96.5, specificity 55.6%] the receiver operator characteristic curve showed the percentage FMD optimal cut-off value as

Effect of intravenous atropine on treadmill stress test results in patients with poor exercise capacity or chronotropic incompetence

Exercise stress test [EST] is one of the main diagnostic and prognostic tests for ischemic heart disease. However, its usefulness depends on achieving target heart rate, then chronotropic incompetence and poor exercise capacity limits its utility. We evaluated the usefulness of atropine administration during the EST to decrease the number of tests with inconclusive results in these patients. We carried out this study in Shahid Madani Heart Center, Tabriz, Iran from September 2003 to December 2004 and comprised of 210 patients undergoing EST. In subjects experiencing fatigue when they achieved 50-75% of target heart rate [THR], or those who failed to achieve their THR, atropine was administered in doses of 0.5 mg per minute until the test conclusion [positive test results or target heart rate achieved] or until a maximum dose of 2 mg was administered Forty-one [19.5%] of the 210 patients required atropine [mean dose: 1.1 mg] during the study. Among patients who received atropine, conclusive test was achieved in 38 cases [92.7%]. Atropine administration resulted in a mean increase in heart rate of 38 beats/min [range 8-71 beat/min]. Atropine injection resulted in a trend towards more positive results of EST in comparison to non-atropine group [31.7% versus 18.3%, p=0.053]. There was no difference in response to atropine in subjects with chronotropic incompetence or poor exercise capacity [p=0.5]. Use of atropine as an adjunct to standard EST can help decrease the number of inconclusive tests. Larger studies are necessary to define the role of atropine in EST and also to evaluate the accuracy of conclusive EST after atropine administration