Hydrocortisone reduces toll-like receptor 4 expression on peripheral CD14[+] monocytes in patients undergoing percutanoues coronary intervention

Evidence from several lines of investigations suggests that Toll-like receptor 4 [TLR4] is involved in atherosclerosis as a bridge between innate and acquired immunity. Percutaneous coronary intervention [PCI] can trigger inflammation through activation of human TLR4 [hTLR4] on monocytes. Hydrocortisone as an anti-inflammatory and immuno-suppressant agent has multiple mechanisms of action. In this study, we aimed at assessing the effects of hydrocortisone on monocyte expression and activity of hTLR4 in patients underwent PCI. Blood samples were taken from a total of 71 patients with chronic stable angina who were scheduled for a PCI, before the intervention. Thirty patients received 100 mg hydrocortisone prior to the procedure. Control group was composed of 41 patients underwent PCI without receiving hydrocortisone. Blood collection was repeated 2 and 4 h after PCI. The expression of hTLR4 on the surface of CD14[+] monocytes and the serum levels of TNF- alpha and IL-1 beta were measured using flowcytometry and Sandwich ELISA. Compared with controls, hydrocortisone significantly reduced monocyte expression of hTLR4 in test group [P<0.01]. In addition, it had a significant effect on reduction of serum concentrations of TNF- alpha and IL-1 beta in test group in a time-dependent manner [P<0.01]. In this study, hydrocortisone was able to reduce the hTLR4/CD14 positive monocytes and its related pro-inflammatory cytokines, thus it can decrease inflammatory responses following PCI

efficacy of hydration with normal saline versus hydration with sodium bicarbonate in the prevention of contrast-induced nephropathy

Contrast-induced acute kidney injury [contrast-induced nephropathy [CIN]] is one of the major causes of hospital-acquired acute renal failure. Volume supplementation is the most effective strategy to prevent acute renal failure caused by contrast; but the effects of sodium bicarbonate regimens are unknown in CIN prevention. The aim of this survey is to compare the efficacy of hydration with normal saline versus hydration with sodium bicarbonate in the prevention of the CIN in patients undergoing coronary angiography. In a clinical trial, 350 patients undergoing coronary interventions were randomized into two groups: One group received normal saline and another group received sodium bicarbonate before and after infusion of the contrast. Patients in both the groups had received N-acetylcysteine. CIN was defined as relative increase in serum creatinine equal to or more than 25% of baseline or increase to 0.5 mg/dl in 48 h after the injection of the contrast. CIN was seen in 46 patients [13.1%] after coronary interventions. Incidence of CIN in patients receiving normal saline [19.4%] was more than in patients receiving sodium bicarbonate [6.9%] [P = 0.001]. Hemodialysis was needed only in one patient who received saline normal. Relative risk to induce CIN in both groups was as 2.8 and was in the range of 1.50-5.25 with confidence interval of 95% and P = 0.001. Thus, the probability of CIN was significantly more in the usage of normal saline. This survey showed that hydration with sodium bicarbonate is superior to hydration with normal saline and has better protection effects

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

Monocyte expression of toll-like receptor-4 in patients with stable angina undergoing percutanoeus coronary intervention

Toll like receptors [TLRs] are well recognized players in inflammatory conditions. Among them TLR-4 is involved in chronic inflammatory processes such as formation of atherosclerotic plaques. The present study was aimed to examine the effects of percutanoeus coronary intervention [PCI] as a revascularization method on monocyte expression of hTLR-4 and on the serum levels of two proinflammatory cytokines [TNF-alpha and IL-1beta]. Blood samples were obtained from 41 patients with stable angina who were candidates for PCI. The samples were collected immediately before and 2h and 4h after PCI. The expression of hTLR-4 on CD14[+] monocytes and the serum levels of TNF-alpha and IL-1beta were measured using flowcytometry and ELISA techniques, respectively. By comparing the frequency of circulating hTLR-4[+]/CD14[+] monocytes at different time points, it was observed that PCI procedure up regulates the monocyte expression of hTLR-4 [p<0.05]. The increase in expression was associated with the elevation of the serum levels of proinflammatory cytokines [p<0.05]. There was a significant correlation between monocyte expression of hTLR-4 and serum levels of TNF-alpha and IL-1beta only before PCI. In spite of parallel increase in the serum levels of proinflammatory cytokines and the monocyte expression of hTLR-4, the correlation did not attain a significant level after PCI intervals. PCI is positively associated with an increase in the monocyte expression of hTLR-4. It is also associated with the elevation in the serum levels of proinflmmatory cytokines. These findings suggest that hTLR-4 monocyte expression may be used as a potential prognostic tool in patients with stable angina undergoing PCI.

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.

The Incidence and Pattern of Coronary Artery Anomalies in the North-West of Iran: A Coronary Arteriographic Study

BACKGROUND AND OBJECTIVES: Coronary artery anomalies are found in approximately 1% of patients undergoing diagnostic coronary angiography (CAG). Angiographic recognition of these vessels is important because of their clinical significance and importance in patients undergoing coronary angioplasty or cardiac surgery. There are fairly enough reports concerning the incidence of coronary anomalies in different geographic areas, but this is the first study among the Iranian population. SUBJECTS AND METHODS: We reviewed the database of the Catheterization Laboratory of Imam Reza and Shahid Madani Hospitals, Tabriz University of Medical Sciences, Iran. Our inquiry included all patients who referred for CAG from other hospitals, between February 2007 and April 2009. Patients with congenital heart diseases, high "take off" of coronary arteries and separate origin of the conus artery from the right coronary sinus (RCS) were excluded. In total, 6065 films were reviewed. RESULTS: Seventy nine (1.30%) patients were found to have coronary anomalies. Seventy five (1.24%) patients had anomalies of origin and distribution, while four (0.06%) had coronary artery fistulae. Most common anomaly was separate ostia of the left anterior descending artery and left circumflex artery, which was found in 42 patients (53.16%) with angiographic incidence of 0.69%. The next most common anomalies were anomalous circumflex artery from RCS/right coronary artery (RCA) {n=17 (21.51%)}, and anomalous RCA arising from left coronary sinus {n=6 (7.59%)}. CONCLUSION: In general, the incidence and pattern of coronary anomalies in our study was similar to earlier reports from different parts of the world.

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

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

Seasonal variation in enzymatic infract size and mortality in patients with ST-segment elevation myocardial infarction

To investigate any seasonal variation in enzymatic size, mortality rate, and localization of ST-segment elevation myocardial infraction [STEMI]. Between March 2003 and September 2006, all patients admitted to the Madani Heart Center, Tabriz, Iran with the diagnosis of acute myocardial infarction [AMI] were included in this observational prospective study. Cases were divided into 4 groups according to the season that MI occurred, and enzymatic size and location were determined for each patient. One thousand and two hundred six cases of AMI were analyzed during the study period. In our study, no seasonal difference was observed in demographic characteristics of patients. Also, no significant seasonal variation was found in enzymatic infract size, MI location, and in-hospital mortality rate. Our findings does not support the hypothesis that enzymatic size, mortality rates, and location of STEMI varies by seasons

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