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

Food Security Is Associated with Dietary Diversity: Tehran Lipid and Glucose Study

This study was undertaken to determine the relationship between food security and individual dietary diversity score [IDDS]. This population-based cross-sectional study was conducted on 200 non-diabetic individuals aged>/=40 years, selected randomly from the Tehran Lipid and Glucose Study. Household food security was measured using a validated United States Department of Agriculture [USDA] 18-item questionnaire and IDDS using a valid and reliable 147-item food frequency questionnaire based on five food groups of the Food Guide Pyramid. Overall, 48.5% of the study subjects had high, 36.0% had borderline, and 15.5% had low food security. Significant inverse correlations were observed between the scores for food security, diversity of fruits and vegetables, and total IDDS. Food secure group had significantly higher total IDDS [4.74 +/- 1.40 vs. 5.15 +/- 1.28, P = 0.033] and score for diversity of fruits [1.48 +/- 1.40 vs. 1.68 +/- 1.28, P = 0.030] as compared to the food insecure group. After adjusting for covariates, higher food security score was associated with lower total IDDS [regression coefficient for a 1-unit difference in diversity score = -0.130, P = 0.040], and score for diversity of fruits [regression coefficient for a 1-unit difference in diversity score = -0.182, P = 0.010]. The results showed an inverse relationship between food security score and dietary diversity score. Intake of different fruits is associated with higher food security

Characterization of suitability of coronary venous anatomy for targeting left ventricular lead placement in patients undergoing cardiac resynchronization therapy

Differences in the quantity and distribution of coronary veins between patients with ischemic and non-ischemic cardiomyopathy might affect the potential for the left ventricular [LV] lead targeting in patients undergoing cardiac resynchronization therapy [CRT]. In the current study, we assessed and compared the suitability of the coronary venous system for the LV lead placement in ischemic and dilated cardiomyopathy. This single-centre study, performed at our hospital, retrospectively studied 173 patients with the New York Heart Association class III or IV who underwent CRT. The study population was comprised of 74 patients with an ischemic underlying etiology and 99 patients with a non-ischemic etiology. The distribution of the veins as well as the final lead positions was recorded. There was no significant difference between the two groups in terms of the position of the available suitable vein with the exception of the posterior position, where the ischemic group had slightly more suitable veins than did the dilated group [48.4% versus 32.1%, p value - 0.049]. There was also no significant difference with respect to the final vein, through which the LV lead was inserted. Comparative analysis showed that the patients with previous coronary artery bypass grafting surgery [CABG] had significantly fewer suitable veins in the posterolateral position than did the non-CABG group [16.3% versus 38.7%, p value = 0.029]. There was, however, no significant difference between the two subgroups regarding the final vein position in which the leads were inserted. The final coronary vein position suitable and selected for the LV lead insertion was not different between the cases with cardiomyopathy with different etiologies, and nor was it different between the ischemic cases with and without a history of CABG. Patients with a history of procedures around the coronary vessel may have an intact or recovered venous system and may, therefore, benefit from transvenous LV lead placement for CRT

Ablation of focal right upper pulmonary vein tachycardia using retrograde aortic approach

The use of diagnostic and therapeutic methods for assessing pulmonary vein due to its status as a main source of ectopic beats for the initiation of atrial dysrrythmias is strongly recommended. We report the case of a 13-year-old girl who was admitted to our hospital with the electrocardiogram manifestation of an ectopic atrial tachycardia. The focus of arrhythmia was inside the right upper pulmonary vein. The patient underwent successful ablation with a conventional electrophysiology catheter via the retrograde aortic approach. We showed that when the origin of atrial tachycardia is in the right upper pulmonary vein, it is possible to advance the catheter into this vein via the retrograde aortic approach and find the focus of arrhythmia. This case demonstrates that right upper pulmonary vein mapping is feasible through the retrograde aortic approach and it is also possible to ablate the arrhythmia using the same catheter and approach

Efficacy of two streptokinase formulations in acute myocardial infarction: a double-blind randomized clinical trial

We sought to evaluate the efficacy and safety of the different trade forms of streptokinase available in our country, namely Heberkinasa [Heberbiotec, Havana, Cuba] and Streptase [Aventis Behring GmbH, Marburg, Germany]. We conducted a double-blind randomized clinical trial to compare the two streptokinase formulations, i.e. Heberkinasa [HBK] or Streptase [STP], in patients with acute myocardial infarction who needed thrombolysis. Thrombolysis success was evaluated angiographically and/or clinically. Clinical follow-up was done 30 days after thrombolysis. We randomly allocated 221 patients with a mean age of 56.9 +/- 10.8 years [males: 88.2%] to HBK [n = 119] and STP [n=102] groups. Baseline clinical and demographic characteristics were similar between the two groups, and the two groups were not significantly different in terms of door-to-needle and pain-to-needle intervals. The rate of complications was not significantly different between the groups [44.1% [HBK] vs. 42% [STP]]. Angiography was done for 158 [71.5%] patients in the first 24 hours [9%] and in the first 72 hours [38.8%] after thrombolysis. Lesion morphology and lesion/patient ratio were not significantly different between the two groups [1.87[HBK] vs. 1.67[STP]]. The two groups were similar with respect to angiographic patency rate [67.5% [HBK] vs. 67.6% [STP]]. The study groups were also similar as regards clinical outcome and complications of both streptokinase formulations. The present study demonstrated that Heberkinasa is as effective and as safe as a standard streptokinase, namely Streptase, in a clinical setting

Comparison of benefits from cardiac resynchronization therapy between patients with ischemic Cardiomyopathy and patients with idiopathic dilated cardiomyopathy

Cardiac resynchronization therapy [CRT] is an effective treatment for patients with moderate to severe heart failure. However, 20-30% of patients remain non-responders to CRT. We sought to identify which patients benefit the most from CRT in regard to the etiology of heart failure. Eighty-three consecutive patients [62 men] who had a biventricular pacemaker inserted at Tehran Heart Center between May 2004 and March 2007 were evaluated retrospectively. The inclusion criteria were comprised of New York Heart Association [NYHA] class III or IV, left ventricular ejection fraction<35%, and QRS>120ms. After 6 months, response was defined as being alive, no hospitalization for cardiac decompensation, and an improvement in NYHA class>1 grade. After 6 months, 60 patients out of the 83 patients were responders. Amongst the 83 patients, 48 had ischemic cardiomyopathy and 35 had non-ischemic cardiomyopathy. A cross-tabulation of response versus etiology showed no significant difference between ischemic versus non-ischemic cardiomyopathy with regard to response to CRT [P=0.322]. According to our study, there was no difference in response to CRT between ischemic versus non-ischemic cardiomyopathy at six months' follow-up

association of air pollution and emergency medical service seeking

There are some reports on the association between air pollution and myocardial infarction, arrhythmia, and mortality due to cardiac problems in susceptible individuals. We aimed to evaluate the association of air pollution and the emergency visits due to cardiovascular diseases, in a specialized heart hospital in Tehran. The study design was cross-sectional. Patients admitted to the emergency ward of Tehran Heart Center were consecutively included. Records of meteorological data for the study period were obtained from Air Quality Control Company that monitors the concentration of air pollutant through its several stations including one near to Tehran Heart Center. The principal component analysis was used to examine the association between daily air pollution level and the number of patients admitted as a result of unstable angina, myocardial infarction, and arrhythmia. The principal component score - reflecting the daily air pollution level- was higher on the admission date of the patients who died in hospital compared to that of the patients who discharged alive from the hospital and the difference was statistically significant. After adjustment for the effect of age, sex, smoking, hypertension, hyperlipidemia and diabetes, a statistically significant relationship between principal component score and the unstable angina and arrhythmia was detected in patients referred to the emergency department. Air pollution was associated with the unstable angina and arrhythmia in patients referred to the emergency department of Tehran Heart Center, adjusted for the effect of other risk factors

Using workload to predict left main coronary artery stenosis in candidates for coronary angiography

Coronary angiography, albeit a safe procedure, may cause serious complications especially in patients with left main stenosis [LMS].This study was designed to investigate the efficacy of workload achieved by exercise tolerance test [ETT] in predicting LMS in candidates for coronary angiography. A total of 743 patients with a positive ETT who subsequently underwent cardiac catheterization were retrospectively studied. Different risk factors were compared among the patients with and without LMS. A multivariate forward stepwise logistic regression analysis was used to identify the main predictors of LMS. Among our 743 patients, 72% were male and 41 [5.5%] had LMS >/= 50%. Patients with LMS, by comparison with those without LMS, were older and were more likely to be male and had higher percentages of ejection fraction less than 35% [EF 7, LMS was found in 8.3% and 3.6%, respectively [P=0.006]. The risk of having LMS in the men with METs 7 [OR=3, P=0.003, 95% CI=1.50-6.00]. Among the patients with LMS, stenosis >/= 70% was found in 44% in METs 7. Lower METs correlated with an increased likelihood of significant LMS in the patients, especially if they were male, who had a positive exercise test and were suspected of coronary artery disease. It is, therefore, advisable that patients with METs

Fractional flow reserve and appropriateness of angioplasty in moderate coronary stenosis

Percutaneous coronary angioplasty [PTCA] of a coronary stenosis without documented ischemia at noninvasive stress testing is often performed, but its benefit is unproven. Coronary pressure- derived fractional flow reserve [FFR] is an invasive index of stenosis severity defined as the ratio of maximal blood pressure in a stenotic vessel to the normal maximal pressure in the same vessel. FFR is a reliable substitute for noninvasive stress testing and values below 75% identifies stenoses with hemodynamic significance. It is a method that can provide a reliable assessment of coronary stenosis especially in those with intermediate lesions. It can highly impact on decision-making in therapeutic planning and prevent many unnecessary procedures that are routinely done in these cases. In the present study, we report the results of FFR measurements in a series of patients, and this is the first report on the FFR measurement in Iran. The FFR measurement was performed for eleven vessels with intermediate stenosis, and in seven lesions [63.6%] it led to changes in the treatment strategy. On the basis of FFR, percutaneous coronary intervention [PCI] was changed into medical follow-up in five lesions, medical follow-up changed to PCI in one lesion, and coronary artery bypass grafting [CABG] changed to medical follow-up in another

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

Moderate Mitral Regurgitation and Coronary Disease: Treatment with Coronary Bypass Alone?

In cases of moderate[2 or 3+ on a scale of 0 to 4+] nonorganic mitral regurgitation [MR] and coronary artery disease, operative strategy continues to be debated between coronary artery bypass grafting alone [CABG] or concomitant valve repair. To clarify the optimal management of these patients, we evaluated the mid-term results of isolated CABG in the study group. From March 2002 to February 2005, 40 consecutive patients [57.5% male, mean age: 62.45 +/- 8.7 years, mean ejection fraction: 44.15 +/- 12.6%, mean New York Heart Association class 2.5 +/- 0.78] with coronary artery disease and moderate MR without organic mitral valve disease [prolapse, rheumatism, etc.] underwent CABG alone. Thirty one [77.5%] patients had either postoperative or follow-up transthoracic echocardiography with mean follow up time of 10.82 +/- 8.12 months. Patient's pre and postoperative data were compared to evaluate the results of isolated CABG on moderate MR. MR was ischemic [with persistent wall motion abnormality] in 25 [62.5%] patients and functional [without persistent wall motion abnormality] in 15 [31.5%]. Considering postoperative and follow up transthoracic echocardiography, 54.8% had no or mild MR [29% MR 1+, 25.8% no MR] and 45.2% had moderate MR [16.1% MR 3+, 29% MR 2+]. ResoluItion of MR was significant [p<0.001], but it had no correlation with ischemic MR [p=0.46], preoperative ejection fraction [p=0.09], LV systolic [p=0.70] and diastolic dimensions [p=0.80]. Seven patients died, 2 in hospital and 5 later. Although for coronary artery disease accompanying moderate nonorganic MR, CABG alone reduces severlity of MR significantly, many patients are left with moderate MR. Preoperative diagnosis of moderate nonorganic MR may warrant concomitant mitral repair

Comparison of Specifications, Short Term Outcome and Prognosis of Acute Myocardial Infarction in Opium Dependent Patients and Nondependents

The effects of opium dependence on prognosis and short term outcome of patients with acute myocardial infarction [AMI] are not clear yet. From March 2004 to August 2004 all male patients admitted with diagnosis of AMI were enrolled. Patients who fulfilled DSM- IV-TR criteria were chosen as opium dependent patients [ODP]. Demographic data, risk factors, peak enzyme levels, location of MI, mortality and ejection fraction were collected and analyzed. We studied the mortality, readmission, functional class, performed revascularizations and coronary angiogram results in a short term follow-up [184 +/- 37 days]. A total number of 160 patients were enrolled, of which 45 [28.1%] were opium dependent. In 137 patients 6 months follow up was completed. Duration of admission was higher in O.D.P [11.3 days versus 8.7, P= 0.03] There was no significant difference in age, EF, location of MI, peak enzymes levels, angiographic findings, risk factors [except for cigarette smoking and triglyceride level], in-hospital mortality, need for readmission, 6 months mortality, functional class, and the need for revascularization. In an unselected cohort of patients admitted with AMI, there was no significant difference in specifications, short term outcome and prognosis of AMI between ODP and nondependents except for duration of hospitalization

Periodontal Disease as a Risk Factor for Coronary Artery Disease

Coronary artery disease is recognized as one of the three major causes of mortality around the world. The role of inflammation in producing coronary artery disease has been established in previous studies. Since periodontal disease, which is highly prevalent, is considered as a cause of inflammation, its influence on producing coronary artery disease was investigated in the present study considering its four main indices. In this case-control study, 60 patients with angiographically proven coronary artery disease were selected as case group After matching for some baseline characteristics including educational level, age, sex, and some established risk factors for coronary artery disease, 60 healthy individuals were selected as control group from a population in whom coronary artery disease had been angiographically ruled out. Then, the existence of periodontal diseases was compared with statistical methods in these two groups, considering four different dental indices. The mean plaque index [PI] was 57.82 +/- 2.92% in cases vs. 35.73 +/- 2.53% in controls [p<0.05]. Mean bleeding on probing [BOP] was 36.3 +/- 3.38% in cases versus 18.6 +/- 2.6% in controls, while mean Attachment Loss>4mm was 35.14 +/- 3.89% and 15.48 +/- 2.79% in cases and controls, respectively [P<0.05]. The mean loss of teeth [LOT] was not significantly different in cases and controls [5.08 +/- 0.52 versus 5.38 +/- 0.53, P>0.05]. Therefore, except for the number of lost teeth, there was a statistically significant difference between these two groups. For an evaluation of independent variables, multiple logistic regression analysis was used. Odds ratio was 1.02 for attachment loss and 2.2 for BOP. Periodontal diseases may be counted as a risk factor for coronary artery disease and it is essential to study the effects of control and management of these diseases as primary and secondary prevention for coronary artery disease in future studies

Impact of Dialysis on Open Cardiac Surgery

Dialysis patients frequently have coronary artery disease but are regarded as high risk patients for coronary artery bypass grafting [CABG]. Between February 2002 and September 2006, seventeen dialysis-dependent patients underwent isolated CABG at our center. CABG was performed under cardiopulmonary bypass [CPB] for all the patients. All cases had been maintained on hemodialysis and the duration of preoperative hemodialysis ranged from 6 to 24 months [mean 13.4 +/- 6.4]. The patients' characteristics, clinical and operative data as well as preoperative and mid-term outcome were reviewed. All patients were men with a mean age of 53 +/- 8.4 years. Mean preoperative ejection fraction was 45.5% +/- 10.4% [range 25 to 60%]. One internal mammary graft was used in 16 [94.1%] patients. Cardiopulmonary bypass and aortic cross-clamp times were 71.3 +/- 18.7 and 40.5 +/- 8.3 minutes respectively. The more frequent complication was prolonged mechanical ventilation in 2 [11.7%], there was no preoperative mortality. In mid-term follow-up [mean time: 11.8 +/- 9.5 months] the mid-term mortality rate was 20% [3 patients]. CABG in chronic renal dialysis patients can be accomplished with acceptable short and mid-term morbidity and mortality