Association between the hepatic lipase promoter region polymorphism [-514 C/T] and the presence and severity of premature coronary artery disease

Background: hepatic lipase [HL] plays a crucial role in lipid metabolism, but there is debate about whether HL acts in a more pro- or more anti-atherogenic fashion. We aimed to examine the relationship between the -514 C/T polymorphism within the HL gene [LIPC] and the risk of angiographically determined premature coronary artery disease [CAD]

Methods: four hundred seventy-one patients with newly diagnosed angiographically documented [>/= 50% luminal stenosis of any coronary vessel] premature CAD were compared to 503 controls [subjects with no luminal stenosis in coronary arteries]. A real-time polymerase chain reaction and high-resolution melting analysis was used to distinguish between the genotypes

Results: there was no significant difference in the distribution of -514 C/T genotypes between the 2 groups in the whole population or in the men, but the examined polymorphism was found to be associated with the presence of CAD in the women [p value = 0.029]. After the application of a multiple logistic regression model, the minor T allele of the LIPC gene was not found to be independently associated with the presence of CAD either in the total population [adjusted OR = 0.97, 95% CI = 0.75-1.25; p value = 0.807] or in the women [adjusted OR = 0.91, 95% CI = 0.59-1.40; p value = 0.650] and in the men [adjusted OR = 1.15, 95% CI = 0.81-1.64; p value = 0.437] separately

Conclusion: our findings suggest that there is no relationship between the LIPC -514 C/T and the risk of premature CAD or its severity in patients undergoing coronary angiography

role of M2000 as an anti-inflammatory agent in toll-like receptor 2/microRNA-155 pathway

Background: M2000 is a newly designed and safe Non-Steroidal Anti-Inflammatory Drug [NSAID]. The aim of this study was to assess the effects of M2000 on expression levels of Suppressor of Cytokine Signaling-1 [SOCS-1] and Src Homology-2 domain containing inositol-5'-phosphatase 1 [SHIP1] proteins via Toll-Like Receptor [TLR] 2/microRNA-155 pathway

Methods: HEK293 TLR2 cell line and Peripheral Blood Mononuclear Cells [PBMCs] were treated by different concentrations of M2000 in MTT assay. RNA was extracted by miRN easy Mini kit. Then, cDNA was synthesized and the expression levels of SOCS1, SHIP1 and miRNA155 were evaluated by Quantitative Real time PCR

Results: Our results showed that M2000 significantly increased the expression levels of SOCS1 and SHIP-1 in Lipopolysachride [LPS]-treated and non-treated cells. Moreover, M2000 decreased expression level of miR-155 in LPS treated PBMCs

Conclusion: M2000 can be used as NSAID in LPS induced inflammation and decrease inflammatory cytokines production by targeting SOCS1, SHIP1 and miR-155 in autoimmune and inflammatory diseases

Analyzing Gensini score as a semi-continuous outcome

Background: Investigators frequently encounter continuous outcomes with plenty of values clumped at zero called semi-continuous outcomes. The Gensini score, one of the most widely used scoring systems for expressing coronary angiographic results, is of this type. The aim of this study was to apply two statistical approaches based on the categorization and original scale of the Gensini score to simultaneously assess the association between covariates and the presence and severity of coronary artery disease [CAD]

Methods: We considered the data on 1594 individuals admitted to Tehran Heart Center with CAD symptoms from July 2004 to February 2008. The participants' baseline demographic and clinical characteristics were collected, and their coronary angiographic results were expressed through the Gensini score. The generalized ordinal threshold and two-part models were applied for the statistical analyses

Results: Totally, 320 [20.1%] individuals had a Gensini score of zero. The results of neither the two-part model nor the generalized ordinal threshold model showed a significant association between Factor V Leiden and the occurrence of CAD. However, based on the two-part model, Factor V Leiden was associated with the severity of CAD, such that the Gensini score increased by moving from a wild genotype to a heterozygote [beta = 0.44; 95% CI: 0.20-0.69 in logarithm scale] or a homozygote mutant [beta = 0.70; 95% CI: 0.28- 1.12 in logarithm scale]. The proportional odds assumption was not met in our data [= 54.26; p value < 0.001]; however, a trend toward severe CAD was also observed at each category of the Gensini score using the generalized ordinal threshold model

Conclusion: We conclude that besides loss of information by sorting a semi-continuous outcome, violation from the proportional odds assumption complicates the final decision, especially for clinicians. Therefore, more straightforward models such as the two-part model should receive more attention while analyzing such outcomes

Angiotensin- converting enzyme insertion/deletion polymorphism and its association with coronary artery disease in an Iranian population

The study of the association between genotype and phenotype is of great importance for the prediction of many diseases and pathophysiological conditions. The relationship between angiotensin-converting enzyme [ACE] gene insertion/ deletion [I/D] polymorphism and pathological processes such as coronary artery disease [CAD] has been investigated previously with discordant results. This study was designed to determine the association between ACE gene I/D polymorphism and CAD in an Iranian population. A total of 1050 individuals who were referred to Tehran Heart Center for coronary angiography were recruited. Six hundred seventy-six CAD-positive patients [documented by coronary angiography and Gensini scores higher than 6] and 374 CAD-negative patients were evaluated for ACE gene I/D polymorphism via the Polymerase Chain Reaction Amplification method. The patients' age, sex, smoking status and its duration as well as familial history of CAD, hypertension, and diabetes mellitus were recorded. Five hundred four [74.6%] of the CAD-positive patients were male, and the mean age of this group was 60 [60 +/- 10]. In the CAD-negative individuals, the mean age was 56 [56 +/- 10] and 196 of them were male [52.4%]. After the analysis of all the groups and gender subgroups, neither genotype nor allele frequency was significantly different between the CAD-positive and CAD-negative groups [p values for genotypes and allele frequencies were 0.494 and 0.397, respectively]. ACE gene I/D polymorphism was not associated with an increased risk of CAD in an Iranian population

Mid-term follow-up of drug-eluting stenting for in-stent restenosis: bare-metal stents versus drug-eluting stents

Despite major advances in percutaneous coronary intervention [PCI], in-stent restenosis [ISR] remains a therapeutic challenge. We sought to compare the mid-term clinical outcomes after treatment with repeat drug-eluting stent [DES] implantation [[DES sandwich] technique] with DES placement in the bare-metal stent [DES-in-BMS] in a [real world] setting. We retrospectively identified and analyzed clinical and angiographic data on 194 patients previously treated with the DES who underwent repeat PCI for ISR with a DES or a BMS. ISR was defined, by visual assessment, as a luminal stenosis greater than 50% within the stent or within 5 mm of its edges. We recorded the occurrence of major adverse cardiac events [MACE], defined as cardiac death, non-fatal myocardial infarction, and the need for target vessel revascularization [TVR]. Of the 194 study participants, 130 were men [67.0%] and the mean +/- SD of age was 5 7.0 +/- 10.4 years, ranging from 37 to 80 years. In-hospital events [death and Q-wave myocardial infarction] occurred at a similar frequency in both groups. Outcomes at twelve months were also similar between the groups with cumulative clinical MACE at one-year follow-up of 9.6% and 11.3% in the DES-in-BMS and the DES-in-DES groups, respectively [p value = 0.702]. Although not significant, there was a trend toward a higher TVR rate in the intra-DES ISR group as compared to the intra-BMS ISR group [0.9% BMS vs. 5.2% DES; pvalue = 0.16]. Our study suggests that the outcome of the patients presenting with ISR did not seem to be different between the two groups of DES-in-DES and DES-in-BMS at one-year follow-up, except for a trend toward more frequent TVR in the DES-in-DES group. Repeat DES implantation for DES restenosis could be feasible and safe with a relatively low incidence of MACE at mid-term follow-up

ALimb-saving procedure for treatment ofarterial cement embolism during lumbar percutaneous vertebroplasty: a case report

As the major hazard of percutaneous vertebroplasty [PV], cement extravasation into the venous system, systemic embolism, and spinal canal has been previously reported. However, to our knowledge, only one case of the arterial migration of cement has been previously reported that is directly associated with this technique without any symptom in the immediate post- intervention and in the follow-up period. An arterial embolus of cement occurred in a 4 6-year-old woman undergoing lumbar PV for breast cancer metastasis. Less than one hour later, the patient complained of severe pain and numbness in her left leg. A diagnosis of acute left leg ischemia due to the acute occlusion of the infrapopliteal arteries by the cement was made. Transluminal angioplasty [PTA] for the infrapopliteal arteries was recommended because there were diffuse and long vessel involvements, leaving no distal targets for bypass vascular surgery. The patient's postoperative course was uncomplicated; the extremity tenderness and mottled skin were improved. A follow-up ultrasound 2 months later revealed an acceptable distal flow in the arteries of the affected limb, and the patient remained asymptomatic [except for a mild leg pain on exertion] at the one-year follow-up examination. In conclusion, PTA may save the limb from amputation in case of peripheral arterial embolism caused by cement during PV

Frequency and predictors of renal artery stenosis in patients undergoing simultaneous coronary and renal catheterization

Atherosclerotic renal artery stenosis [ARAS] remains underdiagnosed due to its nonspecific demonstrations. We aimed to both estimate the frequency of ARAS in high-risk non-selected patients undergoing simultaneous coronary and renal catheterization and possibly identify a predictive model for ARAS using baseline clinical, laboratory, and coronary angiographic variables. The records of 866 patients aged >/= 21 years undergoing simultaneous coronary and renal angiography were retrieved for analysis from our computerized database. The degree of ARAS was estimated visually by experienced attending interventional cardiologists. Lesions with an estimated stenosis of >/= 50% were considered significant. Multivariable stepwise logistic regression models were used to identify the risk factors predicting the presence and extent of ARAS. Of a total of 866 consecutive patients undergoing renal angiography in conjunction with coronary angiography [mean age +/- SD: 63.06 +/- 10.32, ranging from 24 to 89 years], 454 [57%] were men. A total of 345 [39.8%] cases had significant ARAS, 77 [22.3%] of which were bilateral. Using significant ARAS as the dependent variable, six variables were identified as the independent predictors significantly associated with the presence of ARAS, namely age, female sex [male sex was found to be a protector], hypertension, history of renal failure, left anterior descending artery [LAD] stenosis > 50%, and left circumflex artery [LCX] stenosis > 50%. The Gensini score was not found to be a predictor of the presence of ARAS, but it was more likely associated with a trend towards a more extensive ARAS [adjusted OR = 1.00, 95% CI = 1.00-1.01; p value = 0.039]. Other independent determinants of the ARAS extent were the same as the predictors of the ARAS presence. Although risk versus benefit was not tested in this study, it seems that clinicians could consider renal catheterization in combination with coronary angiography particularly in female patients with advanced age and with significant coronary artery stenoses in the LAD and LCX

Discharge against medical advice among inpatients with heart disease in Iran

Discharge against medical advice [DAMA] is a relatively common problem worldwide. We sought to determine the prevalence of and reasons for DAMA among inpatients of our cardiac center. From a total of 20289 discharges from our cardiac teaching hospital, 992 [4.9%] patients at a minimum age of 18 years were cases of DAMA. After excluding 49 cases due to missing data, we retrospectively analyzed our prospectively collected data from 943 patients, who were DAMA cases. Patients' characteristics, including demographic details, reason for discharge, insurance status, and length of stay before discharge, were examined. The mean age of the study patients was 60.7 +/- 13.0 [range, 18-94 years] with a male-to-female ratio of 2.1/1. Lack of consent to surgery or other invasive procedures was the reason cited for DAMA in 31% of the patients, followed by personal or family issues [17%]. No reason for DAMA was reported in 26 [2.8%] of the patients. Women compared to men were more likely to cite "lack of consent to surgery or invasive procedures" as the reason for DAMA [p value = 0.005], whereas men more prevalently stated "personal or family issues" as the reason for DAMA [18.7% vs. 12.7%, p value = 0.022]. The most frequent self-reported reason for DAMA in our cardiac patients was lack of consent to surgery or invasive procedures. This may be because of fear of undergoing invasive procedures such as revascularization. Explaining the stages of a given invasive procedure to patients and comparing its risks versus benefits may lessen impulsive decision-making and DAMA

Determinants of length of stay in surgical ward after coronary bypass surgery: glycosylated hemoglobin as a predictor in all patients, diabetic or non-diabetic

Reports on the determinants of morbidity in coronary artery bypass graft surgery [CABG] have focused on outcome measures such as length of postoperative stay in the Intensive Care Unit [ICU]. We proposed that major comorbidities in the ICU hampered the prognostic effect of other weaker but important preventable risk factors with effect on patients' length of hospitalization. So we aimed at evaluating postoperative length of stay in the ICU and surgical ward separately. We studied isolated CABG candidates who were not dialysis dependent. Preoperative, operative, and postoperative variables as well as all classic risk factors of coronary artery disease were recorded. Using multivariate analysis, we determined the independent predictors of length of stay in the ICU and in the surgical ward. Independent predictors of extended length of stay in the surgical ward [> 3 days] were a history of peripheral vascular disease, total administered insulin during a 24-hour period after surgery, glycosylated hemoglobin [HbA1c], last fasting blood sugar of the patients before surgery, and inotropic usage after cardiopulmonary bypass. The area under the Receiver Operating Characteristic Curve [AUC] was found to be 0.71 and Hosmer-Lemeshow [HL] goodness of fit statistic p value was 0.88. Independent predictors of extended length of stay in the ICU [> 48 hours] were surgeon category, New York Heart Association functional class, intra-aortic balloon pump, postoperative arrhythmias, total administered insulin during a 24-hour period after surgery, and mean base excess of the first 6 postoperative hours [AUC = 0.70, HL p value = 0.94]. This study revealed that the indices of glycemic control were the most important predictors of length of stay in the ward after cardiac surgery in all patients, diabetic or non-diabetic. However, because HbA1c level did not change under the influence of perioperative events, it could be deemed a valuable measure in predicting outcome in CABG candidates

Carotid artery stenting, endarterectomy, or medical treatment alone: the debaste is not over

The management of carotid artery stenosis reduces the risk of stroke and its related deaths. Management options include risk factor modification and medical therapy, carotid endarterectomy [CEA], and carotid artery stenting [CAS]. Although several randomized controlled trials [RCTs], mostly conducted in late-1980s and mi-1990s, have proved CEA to be effective in the prevention of ipsilateral ischemic events in selected patients with carotid artery stenosis, aggressive risk factor modification and medical therapy with recently introduced antiplatelet agents, statins, and more effective antihypertensive medications may have reduced compelling indications for immediate surgery in asymptomatic populations. Also recently, due to improvements in percutaneous techniques and carotid stents, CAS has received wide attention as a potential alternative to CEA. Herein, we review the recent data on the management options of carotid artery stenosis and seek to identify the most appropriate treatment strategy in selected patients with carotid artery stenosis

Role of surgeon in length of stay in ICU after cardiac bypass surgery

We presumed that the surgeon himself has an impact on the results after coronary artery bypass grafting [CABG] as there is no unique protocol for the discharge of post-operative cardiac patients at our institution. Therefore, we examined whether the surgeon himself has an impact on the intensive care unit [ICU] stay of isolated CABG patients. We prospectively studied a total of 570 consecutive patients undergoing elective CABG. Length of stay in the ICU was defined as the number of days in the ICU unit post-operatively. Seven operating surgeons were classified in 3 categories on the basis of the mean hospital stay of their patients [1, 2 and 3 if the mean total patients' stay in hospital was <8 days, between 8 to 10 days, and longer than 10 days; respectively]. Using a multivariable regression model, we determined the independent predictors of length of stay in the ICU [> 48 hours] and examined the role of surgeon in this regard. Incidence of post-operative arrhythmia and length of ICU stay were higher in the patients of surgeon category 3 than those of surgeon categories 1 and 2. Surgeon category 3 also operated on patients with higher Euro SCOREs than did surgeon categories 1 and 2. With the aid of a multivariable stepwise analysis, three variables were identified as independent predictors significantly associated with ICU length of stay: age, history of cerebrovascular accident, and surgeon category. Surgeon category may independently predict a prolonged length of stay in the ICU. We suggest that a unique discharge protocol for post-CABG patients be considered to restrict the role of surgeon in the ICU stay of these patients

Monitoring of anticoagulant therapy in heart disease: considerations for the current assays

Clinicians should be aware of new developments to familiarize themselves with pharmacokinetic and pharmacodynamic characteristics of new anticoagulant agents to appropriately and safely use them. For the moment, cardiologists and other clinicians also require to master currently available drugs, realizing the mechanism of action, side effects, and laboratory monitoring to measure their anticoagulant effects. Warfarin and heparin have narrow therapeutic window with high inter-and intra-patient variability, thereby the use of either drug needs careful laboratory monitoring and dose adjustment to ensure proper antithrombotic protection while minimizing the bleeding risk. The prothrombin time [PT] and the activated partial thromboplastin time [aPTT] are laboratory tests commonly used to monitor warfarin and heparin, respectively. These two tests depend highly on the combination of reagent and instrument utilized. Results for a single specimen tested in different laboratories are variable; this is mostly attributable to the specific reagents and to a much lesser degree to the instrument used. The PT stands alone as the single coagulation test that has undergone the most extensive attempt at assay standardization. The international normalized ratio [INR] was introduced to normalize-all PT reagents to a World Health Organization [WHO] reference thromboplastin preparation standard, such that a PT measured anywhere in the world would result in an INR value similar to that which would have been achieved had the WHO reference thromboplastin been utilized. However, INRs are reproducible between laboratories for only those patients who are stably anticoagulated with vitamin K antagonists [VKAs] [i.e., at least 6 weeks of VKA therapy], and are not reliable or reproducible between laboratories for patients for whom VKA therapy has recently been started or any other clinical conditions associated with a prolonged PT such as liver disease, disseminated intravascular coagulation, and congenital factor deficiencies. In contrast to marked progress in the standardization of PT reagents for INR reporting, no standardization system has been globally adopted for standardization of PTT reagents. Recently College of American Pathologists recommend that individual laboratories establish their own therapeutic range by using aPTT values calibrated against accepted therapeutic unfractionated heparin [UFH] levels calibrated against accepted therapeutic UFH levels performing anti-Xa test [which is the most accurate assay for monitoring UFH therapy]. Herein, we review recent data on the monitoring of conventional anticoagulant agents. Marked interlaboratory variability still exists for PT, INR, and PTT tests. Further research should be focused on improving the standardization and calibration of these assays

echocardiographic study of heart in a group of male adult elite athletes

Severe and prolonged physical training is associated with morphological and physiological cardiac changes, often termed as the "athlete's heart". Echocardiographic features peculiar to elite Iranian athletes have not been previously described. The aim was to examine the echocardiographic characteristics of highly trained Iranian athletes involved in three different sports. We studied cardiac morphology and function as assessed by rest echocardiography in 50 elite adult male athletes referring to a university hospital in Tehran between February 2001 and March 2006. Resting ejection fraction, interventricular septal wall thickness [IVSWT], left ventricular posterior wall thickness [LVPWT], left ventricular internal end diastolic dimension [LVEdD], left ventricular internal systolic dimension [LVIsD], left ventricular [LV] mass, and relative wall thickness [RWT] were measured. The control group consisted of 50 age- and weight-matched normal healthy men. Of the athletes, 38 were engaged in predominantly dynamic [running and soccer] and 12 in predominantly static [weightlifting] sports. The overall mean LVEdD [51.06 +/- 5.49mm] and IVSWT [10.24 +/- 1.43mm] were higher in the athletes than those in the normal subjects. The mean of IVSWT in the 38 endurance-trained athletes was significantly more than that of the 12 strength-trained athletes [11.1 mm vs. 10.3 mm, P < 0.05]. LVEdD was also greater in the endurance-trained athletes, but the difference was not statistically significant [51.2 mm vs. 50.6 mm]. Our results of higher LVEdD and IVSWT in Iranian male athletes are in line with previous reports. To generalize the results, we require more studies with larger sample sizes [with female athletes included]

Short- term outcomes and mid-term follow-up after coronary angioplasty in patients younger than 40 years of age

Stenting is currently the standard of care in percutaneous coronary intervention [PCI]. Whether young patients remain at increased risk after PCI in the present stent era has not been investigated widely. We evaluated angiographic characteristics and short- and mid-term outcomes in patients younger than 40 years of age who underwent PCI. From April 2003 to March 2005, prospective data were collected in 118 consecutive patients, who were less than 40 years of age and underwent PCI at our referral center. The PCI outcomes in these patients were compared to those in 354 patients, randomly selected from 2493 patients older than 40 years of age in our database. Follow-up was scheduled at 1 month, 5 months, and 9 months through clinic visits, telephone interviews, and reviewing hospital records. Patients<40 years of age were more often male [91.5% vs. 71.8%, P<0.001], current smokers [33.9% vs. 15.2%, P<0.001], and had more family history of coronary artery disease [38.1% vs. 21.8%, P<0.001] and myocardial infarction [44.1 vs. 31.1, p=0.01], while diabetes mellitus [6.8% vs. 22.1%, P<0.001], hypertension [13.6% vs. 35.3%, P<0.001], and hyperlipidemia [34.7% vs. 44.8%, P=0.055] were less common in these patients. There were no significant differences between the two groups regarding vessel involvement, reference vessel diameter, stenosis rate [before and after procedure], and lesion characteristics, with an exception that angulated lesions were more common in the patients. 40 years of age [P<0.05]. The young patients, who underwent PCI, presented more frequently with single-vessel disease [61% vs. 46%, P=0.01].The vessel and lesion sites of PCI and clinical success rates were similar in these age groups. Usage of stent was high and similar, and drug- eluting stent use was not significantly different between the two groups. With a high procedural success [94.9% vs. 91.8%], intra-hospital and late complications were very low and similar in both groups. Percutaneous coronary intervention is a safe and effective procedure for young patients, and major adverse cardiac events are similar in young and older patients

Clinical and angiographic characteristics of myocardial bridegs: a descriptive report of 19 cases and follow-up outcomes

Muscle fibers overlying the intramyocardial segment of an epicardial coronary artery are termed myocardial bridge [MB]. The aim of this study was to analyze the mid-term outcome of MB and to examine its possible association with angiographic findings and concomitant cardiac pathologies such as hypertrophic cardiomyopathy [HCM]. From a total of 3218 patients admitted for coronary angiography during 9 consecutive months, 28 [0.9%] were diagnosed with MBs with stenoses.50%. Of these, 19 referred for follow-up with a median duration of 18 months. HCM was present in 5 patients [26.3%], of whom 4 had MB as the sole finding in angiography. Of the 19 patients, 14 had diastolic dysfunction. In follow-up, 2 patients were treated with revascularization strategies due to the concomitant coronary artery disease and in 2, syncope occurred. For two patients, an intra-cardiac device and a permanent pacemaker were implanted. Three patients with MB as the sole finding in angiography were readmitted because of chest pain. Diastolic dysfunction may contribute to the presentation of symptoms of muscle bridging. Also, myocardial bridging as the only finding in coronary angiography is highly associated with hypertrophic cardiomyopathy and may help to detect this group of patients. The mid-term outcome of myocardial bridges is favorable

Outcomes of primary percutaneous coronary intervention in acute myocardial infarction at tehran heart center

To describeour experience of primary angioplasty in ST-segment elevation myocardial infarction. During a period of 2 years [April 2003 to May 2005], 83 high-risk patients presenting with acute ST-segment elevation myocardial infarction underwent primary angioplasty subject to availability ofballoon dilation within 90 min of admission. In total, 73 stents were implanted; 69 were bare metal stents, while the remaining 4 were paclitaxel-eluting stents. Of the 83 patients, 8 presented with cardiogenic shock. Follow-up was for a period of 9 months. All angiographic, in-hospital and clinical outcomes were recorded on a database. The procedure was successful in 79 of the 83 patients [95%] and unsuccessful in 4 [5%]. Of these 4 patients, 3 died and 1 was treated medically. In 65 patients with zero perfusion, angioplasty was successful in 61 [93.8%], while it was completely successful [100%] in the remaining 18 patients with thrombolysis in myocardial infarction grade 3 perfusion.Vessel patency was achieved in 95% with thrombolysis in myocardial infarction grade 3 flow present in 93%. A total of 7 [8.5%] patients died while in the hospital. Of the 8 with initial cardiogenic shock on presentation, 4 [50%] died in the hospital and of the remaining 4, 1 was lost at 9-month follow-up. In-hospital reocclusion and reinfarction did not occur in any patient. Theresults suggest that primary angioplasty is logistically feasible in our center with good clinical outcomes