Leuko-Glycemic Index in the Prognosis of Acute Myocardial Infarction; a Cohort Study on Coronary Angiography and Angioplasty Registry.

Introduction: The leuko-glycemic index (LGI), a combined index of patient leukocyte counts and blood glucose levels, has been shown to predict the prognosis of myocardial infarction (MI) patients. Our study aims to investigate the performance of LGI in prediction of outcomes in a population of diabetic and non-diabetic MI patients. Methods: This observational registry-based cohort study was performed on acute myocardial infarction (AMI) patients. Participants were sub-grouped according to their diabetes status and the calculated optimal LGI cut-off value. The outcomes of the study were the length of hospital stay, and in-hospital and 30-day mortality. Results: A total of 296 AMI (112 diabetic and 184 non-diabetic) patients were included in the study. The optimal cut-off value of LGI in the diabetic and non-diabetic groups was calculated as 2970.4 mg/dl.mm3 and 2249.4 mg/dl.mm3, respectively. High LGI was associated with increased hospital admission duration in non-diabetic patients (p = 0.017). The area under the curve (AUC) of LGI for prediction of in-hospital mortality was 0.93 (95% CI: 0.87 to 1.00) in the diabetic group and 0.92 (95% CI: 0.85 to 0.99) in the non-diabetic group. LGI had a sensitivity and specificity of 90.00%, and 93.14% in prediction of in-hospital mortality in the diabetic group compared to 77.77% and 90.85% in the non-diabetic group. We observed 4 post-discharge mortalities in our patient group. Conclusion: Our study demonstrated that higher LGI predicts in-hospital mortality in both diabetic and non-diabetic patients, while the length of hospital stay was only predicted by LGI levels in non-diabetic patients.

Prognostic Value of The Leuko-Glycemic Index in Acute Myocardial Infarction; a Systematic Review and Meta-Analysis.

Introduction: In recent years, studies have provided evidence on the prognostic value of the leuko-glycemic index (LGI) in acute myocardial infarction (MI), but there is a lack of consensus. In addition, various reported cut-offs for LGI have raised concern regarding its clinical applicability. So, to conclude, through this systematic review and meta-analysis, we aimed to investigate all available evidence on the prognostic value of LGI in acute MI. Methods: Two independent researchers summarized records available in the four main databases of Medline (Via PubMed), Embase, Scopus, and Web of Science until 15 Sep 2022. Articles studying the prognostic value of the LGI in acute MI were included. Finally, sensitivity, specificity, prognostic odds ratio, and the area under the curve (AUC) for LGI were analyzed and reported. Results: Eleven articles were included (3701 patients, 72.1% male). Based on the analyses, AUC, sensitivity, and specificity for LGI in prediction of mortality following acute MI were 0.77 (95% CI: 0.73 to 0.80), 0.75 (95% CI: 0.62 to 0.84), and 0.66 (95% CI: 0.51 to 0.78), respectively. Positive and negative post-test probability of LGI in prediction of mortality were 21% and 5%, respectively. AUC, sensitivity, and specificity for LGI in prediction of major cardiac complications after acute MI were 0.81 (95% CI: 0.77 to 0.84), 0.84 (95% CI: 0.70 to 0.92), and 0.64 (95% CI: 0.49 to 0.84), respectively. Also, the Positive and negative post-test probability of LGI in this regard were 59% and 13%, respectively. Conclusion: Although the results demonstrated that the LGI could predict mortality and acute cardiac complication after MI, the low post-test probability of LGI in risk stratification of patients raises questions regarding its applicability. Nevertheless, as most of the available studies have been conducted in the Latino/Hispanic population, further evidence is warranted to generalize the validity of this tool to other racial populations.

Coronary Artery Bypass Grafting in advance aged patients.

INTRODUCTION: This study aimed to assess the impact of coronary artery bypass grafting (CABG) on outcomes in elderly patients compared to younger patients. METHOD: An observational case-control study was conducted involving 535 patients, divided into two groups: older adults (≥75 years) and younger adults (<75 years). All patients underwent CABG following a similar protocol. The primary endpoints focused on early post-procedure outcomes, including in-hospital mortality and the duration of ICU or hospital stay. Patients were followed up for six months, and secondary study endpoints included long-term mortality, left ventricular ejection fraction, re-hospitalization rates, and repeated revascularization. RESULTS: 535 patients who underwent CABG were enrolled in this study. The smoking habit was significantly higher among younger adults (38.2% vs. 12.5%, P=0.001). Hypertension was more prevalent among older adults than younger adults (75% vs. 60%, P=0.044). LDL cholesterol serum levels were higher among younger adult patients (94.9±32.5 vs. 80.9±32.9, P=0.028). In-hospital death was not significantly different between younger and older adults (2.8% vs. 5.0%, P=0.34). Mortality in the six-month follow-up was non-significantly higher in the elderly (2.1% vs. 8.1%, P=0.06).A significant proportion of patients in both groups (46.9% in younger patients vs. 40% in older ones, P=0.40) received dual antiplatelet therapy (DAPT) prior to CABG due to a recent myocardial infarction and receipt of a new stent, but without increased major bleeding in both groups. CONCLUSION: CABG should be considered a viable treatment option for elderly patients with acceptable operative risk in current clinical practice.

Differences in gender and outcomes following isolated coronary artery bypass graft (CABG) surgery.

BACKGROUND: Gender impacts pre-, intra-, and postoperative parameters and outcomes following coronary artery bypass graft (CABG) with conflicting results. This study aimed to identify differences in preoperative, intraoperative, and postoperative parameters. It also seeks to compare the postoperative complications and mortality between two genders who had CABG surgery. METHOD: This prospective observational study included patients who had isolated CABG and were divided based on gender. Demographic information, underlying comorbidities, drug history, clinical and laboratory data at the time of referral, operative characteristics, postoperative variables, and mortality outcomes were tracked during hospitalization and six months after discharge. RESULTS: Three hundred twenty patients were enrolled in the study during its duration. 71% were male. Women were older (62.40±9.03 vs. 59.99±9.81 years, p= 0.011) and had more dyslipidemia (p=0.003), hypertension (p=0.000), and diabetes (p=0.001), whereas men admitted with more myocardial infarction (MI) (p=0.011) and had lower Ejection fraction (EF) (p=0.001). They also had lower EF post-surgery (p <0.001) and six months after discharge (p = 0.006). However, the number of vessels involved was not different between genders (p=0.589), but the number of grafts was higher in men (p=0.008).There was no statistically significant difference in overall mortality rates between the two groups (4.42% and 6.38% in men and women, respectively, p= 0.464). CONCLUSIONS: The women had more underlying comorbidities than men. Furthermore, there were some differences in the intra-operative parameters and postoperative complications between the two genders, but there was no difference in postoperative mortality in our setting.

Risk Factors of Readmission in COVID-19 Patients; a Retrospective 6-Month Cohort Study.

Introduction: The available literature regarding the rate of readmission of COVID-19 patients after discharge is rather scarce. Thus, the aim in the current study was to evaluate the readmission rate of COVID-19 patients and the components affecting it, including clinical symptoms and relevant laboratory findings. Methods: In this retrospective cohort study, COVID-19 patients who were discharged from Imam Hossein hospital, Tehran, Iran, were followed for six months. Data regarding their readmission status were collected through phone calls with COVID-19 patients or their relatives, as well as hospital registry systems. Eventually, the relationship between demographic and clinical characteristics and readmission rate was assessed. Results: 614 patients were entered to the present study (mean age 58.7±27.2 years; 51.5% male). 53 patients were readmitted (8.6%), of which 47 patients (7.6%) had a readmission during the first 30 days after discharge. The reasons for readmission were relapse of COVID-19 symptoms and its pulmonary complications in 40 patients (6.5%), COVID-19 related cardiovascular complications in eight patients (1.3%), and non-COVID-19 related causes in five patients (0.8%). Older age (OR=1.04; 95% CI: 1.01, 1.06; p=0.002) and increased mean arterial pressure during the first admission (OR=1.04; 95% CI: 1.01, 1.08; p=0.022) were found to be independent prognostic factors for the readmission of COVID-19 patients. Conclusion: Readmission is relatively frequent in COVID-19 patients. Lack of adequate hospital space may be the reason behind the early discharge of COVID-19 patients. Hence, to reduce readmission rate, extra care should be directed towards the discharge of older or hypertensive patients.

Comparison between surgery and fibrinolytic therapy in prosthetic valve thrombosis: A systematic review and meta-analysis.

BACKGROUND: Prosthetic valve thrombosis (PVT) is a rare but life-threatening complication. Surgery and fibrinolytic therapy (FT) are the two main treatment options for PVT. The choice between surgery and FT has always been a matter of debate. Previous studies have shown that although the mortality rate is higher in surgery, complications are less frequent than in FT. We aimed to perform a systematic review and meta-analysis to compare the results of surgery and FT in PVT. METHODS: A systematic review of the literature was performed through Medline, Embase, Scopus, and Web of Science, encompassing all studies comparing surgery and FT in PVT. The rate of each complication and risk ratio (RR) of complications in surgery and FT were assessed using random-effects models. RESULTS: Fifteen studies with 1235 patients were included in the meta-analysis. The pooled risk of the mortality was not significantly different between FT and surgery in patients with PVT (pooled RR = 0.78, 95% confidence interval [CI]: 0.38-1.60, I² = 61.4%). The pooled risks of thromboembolic events (pooled RR = 4.70, 95% CI: 1.83-12.07, I² = 49.6%) and major bleeding (pooled RR = 2.45, 95% CI: 1.09-5.50, I² = 41.1%) and PVT recurrence (pooled RR = 2.06 95% CI: 1.29-3.27, I² = 0.0%) were significantly higher in patients who received FT. CONCLUSION: Surgery may be safer and with fewer complications than FT for PVT treatment. However, randomized clinical trials are needed to determine the proper treatment for PVT.

Is cardiac Troponin I Considered as A Predictor of In-hospital Mortality among COVID-19 Patients? A Retrospective Cohort Study.

OBJECTIVE: To describe the levels of troponin I in COVID-19 patients and its role in the prediction of their in-hospital mortality as a cardiac biomarker. METHODS: The current retrospective cohort study was performed on the clinical records of 649 COVID-19-related hospitalized cases with at leat one positive polymerase chain reaction (PCR) test in Tehran, Iran from February 2020 to early June 2020. The on admission troponin I level divided into two groups of ≤0.03ng/mL (normal) and >0.03ng/mL (abnormal). The adjusted COX-regression model was used to determine the relationship between the studied variables and patient's in-hospital mortality. RESULTS: In this study, the median age of subjects was 65 years (54.8% men) and 29.53% of them had abnormal troponin I levels. Besides, the in-hospital mortality rate among patients with abnormal troponin I levels was found to be 51.56%; whereas, patients with normal levels exhibited 18.82% mortality. Also, the multivariable analysis indicated that the risk of death among hospitalized COVID-19 patients displaying abnormal troponin I levels was 67% higher than those with normal troponin I levels (Hazard ratio=1.67, 95% confidence interval=1.08-2.56, p=0.019). CONCLUSION: It seems that troponin I is one of the important factors related to in-hospital mortality of COVID-19 patients. Next, due to the high prevalence of cardiac complications in these patients, it is highly suggested to monitor and control cardiac biomarkers along with other clinical factors upon the patient's arrival at the hospital.

Dual antiplatelet therapy before coronary artery bypass grafting in patients with myocardial infarction: a prospective cohort study.

BACKGROUND: Dual antiplatelet therapy (DAPT) in patients with MI who are candidates for early coronary artery bypass grafting (CABG) can affect intraoperative and postoperative outcomes. Therefore, the aim of this study was to evaluate the effect of DAPT up to the day before CABG on the outcomes during and after surgery in patients with MI. METHODS: In this prospective cohort study, 224 CABG candidate patients with and without MI were divided into two groups: (A) patients without MI who were treated with aspirin 80 mg/day before surgery (noMI-aspirin group; n = 124) and (B) patients with MI who were treated with aspirin 80 mg/day before surgery and clopidogrel (Plavix brand) at a dose of 75 mg/day (MI-DAPT group; n = 120). Dual or mono-antiplatelet therapy continued until the day before surgery. Patients were followed to assess in-hospital and 6-months outcomes. RESULTS: The in-hospital mortality in MI-DAPT group was similar with noMI-aspirin group (OR 4.2; 95% CI 0.9-20.5; p = 0.071). The prevalence of CVA (p = 0.098), duration of hospital stay (p = 0.109), postoperative ejection fraction level (p = 0.693), diastolic dysfunction grade (p = 0.651) and postoperative PAP level (p = 0.0364) did not show difference between two groups. No mild or severe bleeding was observed in the patients. Six-month follow up showed that number of readmissions (p = 0.801), number of cases requiring angiography (p = 0.100), cases requiring re-PCI (p = 0.156), need for re-CABG (p > 0.999) and CVA (p > 0.999) did not differ between the two groups. During the 6-month follow-up, out-hospital mortality did not differ significantly between the two groups (p = 0.446). CONCLUSIONS: A 6-month follow-up showed that DAPT with aspirin and clopidogrel before CABG in patients with MI has no effect on postoperative outcomes more than mono-APT with aspirin. Therefore, DAPT is recommended in the preoperative period for these patients.

Dual Antiplatelet Therapy before Coronary Artery Bypass Grafting; a Systematic Review and Meta-Analysis.

INTRODUCTION: Currently, the basis of acute coronary syndrome (ACS) therapy is dual antiplatelet therapy (DAPT) with Aspirin as a nonsteroidal anti-inflammatory drug and clopidogrel as adenosine diphosphate receptor antagonists. Therefore, the aim of the present systematic review is to answer that should DAPT with Aspirin and clopidogrel be continued until coronary artery bypass grafting (CABG) in patients who have ACS? METHODS: The search for relevant studies in the present meta-analysis is based on three approaches: A) systematic searches in electronic databases, B) manual searches in Google and Google Scholar, and C) screening of bibliography of related original and review articles. The endpoints included mortality rate, myocardial infarction (MI), cerebrovascular accident (CVA), reoperation, re-exploration, other cardiac events, renal failure, length of ICU and hospital stay, chest tube drainage and blood product transfusion after CABG. RESULTS: After the initial screening, 41 articles were studied in detail, and finally the data of 15 studies were included in the meta-analysis. DAPT before CABG in patients with ACS does not increase the rate of mortality, CVA, renal failure, MI, and other cardiac events, but increases reoperation, re-exploration, length of ICU, and hospital stay. Chest tube drainage and blood product transfusion rate significantly increased in the DAPT group compared to the control group (non-antiplatelet or Aspirin alone). Increase in chest tube drainage and blood product transfusion rate indicates an increase in bleeding, so increase in reoperation, re-exploration to control bleeding, and, subsequently, increase in the length of ICU and hospital stay are expected. CONCLUSIONS: DAPT with Aspirin and clopidogrel before CABG in patients with ACS does not increase the rate of mortality, CVA, renal failure, MI, and other cardiac events despite more bleedings, and it may be suggested before CABG for better graft patency.

A Randomized Double Blind Placebo Controlled Trial Examining the Effects of Pentoxifylline on Contrast Induced Nephropathy Reduction after Percutaneous Coronary Intervention in High Risk Candidates.

Contrast-induced nephropathy (CIN) (known as contrast-induced acute kidney injury) occurs as a result of acute worsening of renal function following a procedure with administration of iodine contrasts agent and remains a substantial concern in clinical practices. The purpose of this study is to investigate the preventive effect of Pentoxifylline supplementation on reduction of CIN occurrence after percutaneous coronary intervention among patients who were high risk of CIN according to Mehran score. In randomized, double-blind clinical trial patients who undergo coronary angiography with Mehran Score ≥ 11 consisted of our population. Patients in a ratio 1:1, divided into two groups received saline 0.9% plus N-acetyl cysteine and Pentoxifylline 400 mg three times per day 24 h before angiography until 48 h after angiography. In control group, the patients received placebo instead of PTX in a same manner as the control group. The endpoint was the incidence of CIN defined as creatinine increase of 0.5 mg/dL within 2 days after contrast. There were no significant differences in baseline characteristics. CIN occurred in 3 (5.5%) and 4 (7.3%) patients of the both groups (Pentoxifylline and control), respectively (p = 0.69; incidence odds ratio 1.36; 95% CI 0.29-6.38). No significant differences were seen in secondary outcome measures and changes in the level of creatinine (p = 0.54). In high-risk patients undergoing coronary angiography pentoxifylline supplementation had protection effect against contrast-induced nephropathy greater than placebo based hydration, but, not supported by our data.

Predictive Factors of Mortality in Acute Amphetamine Type Stimulants Poisoning; a Review of 226 Cases.

INTRODUCTION: Amphetamine type stimulants (ATS) such as amphetamine and methamphetamine (MA) are one of the most important causes of poisoning in the world. In this study we aimed to define the predictive factors of mortality in acute ATS poisoning patients. METHODS: This is a retrospective cross-sectional study on all cases with acute ATS poisoning who were referred to a referral center for poisoning, Tehran, Iran, from April 2011 to March 2014. Using patients' medical records, demographic data, route of exposure, type and amount of ATS, the cause of poisoning, clinical presentations, and electrocardiogram (ECG) and laboratory findings, as well as patient's outcomes were collected and analyzed regarding the independent predictive factors of mortality. RESULTS: 226 cases with the mean age of 32.9 ± 10.9 years were studied (77% male). MA was the most abused ATS (97.4%) and the most frequent route of exposure was oral (55.3%). The mortality rate was 5.4%. There was a significant association between agitation (p = 0.002), seizure (p = 0.001), loss of consciousness (p < 0.001), creatine phosphokinase level (p = 0.002), serum pH (p = 0.002), serum HCO3 (p = 0.02), and PCO2 (p = 0.01) with mortality. However, serum HCO3 [OR=1.27 (95% CI: 1.07-1.50); p value=0.005], PCO2 [OR=0.89 (95% CI: 0.84-0.96); p value=0.002], and loss of consciousness [OR=0.019 (95% CI: 0.003-0.106); p value=0.000] were the only independent predictive factors of mortality. CONCLUSION: PCO2 ≥ 51 mmHg, serum bicarbonate ≤ 22.6 mEq/L, and loss of consciousness on admission could be considered as prognostic factors of mortality in acute ATS poisoning cases presenting to emergency department.

Resistant Hypertension due to Fibromuscular Dysplasia in a Young Male: A Rare Case Report.

Fibromuscular Dysplasia (FMD) is a sporadic non-atherosclerotic disease. FMD has been established in nearly every arterial bed. However, the most frequent arteries affected are the renal and carotid arteries. Disease presentation may vary broadly, depending upon the arterial bed complication and the severity of illness. Hypertension, particularly resistant type, headache and dizziness are the most common presentations. String of beads appearance in angiographic views due to post-stenotic aneurysms is the characteristic view. It is most commonly described in young aged females; but in rare male cases has also been reported. Moreover, balloon angioplasty is standard and effective therapy for FMD. We present a young 28-year-old man who was referred for evaluation of resistant hypertension for nearly 3 years without comprehensive workup. The patient underwent renal artery angiography which confirmed beading narrowing of the right renal artery with significant stenosis at mid portion compatible with FMD; and balloon angioplasty was done. This case highlights that FMD should be kept in mind as a rare cause of resistant hypertension in young males; although it is most common in young females.

Successful Treatment of Aluminium Phosphide Poisoning by Extracorporeal Membrane Oxygenation.

Aluminium phosphide (ALP) is one of the most commonly used pesticides worldwide with high mortality rates. Cellular damage and cardiorespiratory failure are the most common causes of mortality and morbidity after poisoning. It is supposed that giving enough time to the patient to survive, the most critical hours after exposure may help the cardiovascular system to recover itself and save the patient's life. During a training workshop for medical extracorporeal membrane oxygenation (ECMO), a 28-year-old ALP-poisoned male was referred to us. Fifty minutes after admission, he developed hypotension and bradycardia and was transferred to ICU. On the second venous blood gas, he had severe metabolic acidosis. After starting the patient on the routine treatment of ALP poisoning, he was a candidate for veno-arterial (VA) ECMO. After three days, lactate level decreased and his general condition improved. On day four, the patient was completely separated from the ECMO machine with acceptable echocardiography and ejection fraction of 40%. One day later, he was extubated, sent to the ward and subsequently discharged in good condition. We suggest this method of treatment for severe ALP poisoning as well as any other poisoning that causes cell toxicity and abrupt cardiovascular or respiratory failure.

Prevalence, main determinants, and early outcome of patients with atrial fibrillation hospitalized with ischemic stroke: evaluation of the value of risk assessment scores for predicting risk of stroke or major bleeding following anticoagulation therapy.

BACKGROUND: Despite controllable nature of atrial fibrillation in most patients, it increases the risk of atrial thrombosis leading to ischemic stroke. The researchers assessed the underlying risk factors for brain stroke and also major bleeding in patients with ischemic stroke and atrial fibrillation. METHODS: Among 900 patients hospitalized with the diagnosis of ischemic brain stroke between 2013 and 2014, 100 patients had atrial fibrillation that included into this cross-sectional study. The risk of stroke and major bleeding was assessed using CHA2DS2-VASc and HAS-BLED risk scores, respectively; but new stroke was not considered. RESULTS: Of 900 patients with evidences of ischemic stroke, 100 had atrial fibrillation with an overall prevalence of 11.1%. Mean CHA2DS2-VASc score was 4.35 ± 1.76 that the total score was ≥ 2 points in 93% of subjects showing necessity to anticoagulation therapy in 93% of the patients before recent stroke. Mean HAS-BLED score was 2.83 ± 1.30 that was ≥ 3 in 61% indicating risk of bleeding in 61% of all patients. 31% of the patients had previous history of atrial fibrillation, but only less than half of them (51%) were under treatment with warfarin, and also the measured INR was lower than the therapeutic range in 95.5% of individuals on warfarin therapy. In-hospital mortality was reported in 9% of all study subjects. The main determinants of early mortality included history of stroke, renal failure, presence of coronary artery disease, acetylsalicylic acid use, and Clopidogrel use. The analysis using the ROC curve showed that both CHA2DS2-VASc score (AUC = 0.788) and HAS-BLED score (AUC = 0.960) could strongly predict in-hospital mortality. CONCLUSION: The patients with atrial fibrillation hospitalized with ischemic stroke showed an important absolute risk of further stroke and early mortality. Despite substantiated advantages of warfarin prophylaxis, its limited application is still very common.

In-hospital outcomes after primary percutaneous coronary intervention according to left ventricular ejection fraction.

BACKGROUND: The primary objective of primary percutaneous coronary intervention (pPCI) in patients with acute ST-segment elevation myocardial infarction (STEMI) is not only to restore the blood flow in the infarct-related artery, but also to save the patients' quality and duration of their life. Since left ventricular ejection fraction (LVEF) is a known predictor of clinical outcomes in STEMI patients, the possible association between characteristics of a large group of patients who undergo pPCI with LVEF and death was evaluated. METHODS: This prospective cohort study included 304 patients who had undergone pPCI between 2009 and 2011. The association between LVEF and in-hospital outcomes of patients was assessed. RESULTS: LVEF ≤ 25%, 25% < LVEF < 50%, and LVEF ≥ 50% were presented in 23 (7.6%), 150 (49.3%), and 128 (42.1%) of the patients, respectively. Three patients (0.01%) died before echocardiography. There was no significant difference among aforementioned three groups regarding baseline characteristics, except age (P = 0.012) and sex (P = 0.016). Cumulative number of cardiogenic shock and death were 7 (2.3%) and 22 (7.2%), respectively; with significant differences between three LVEF groups. Age more than 70 years old, pulmonary edema, systolic blood pressure < 100 mm Hg, shock, post-PCI thrombolysis in myocardial infarction (MI) flow grade, corrected thrombolysis in MI frame count, angiographic success and ST-segment resolution showed significant association with death (P < 0.050). CONCLUSION: This study not only demonstrates that LVEF ≤ 50% is associated with a higher incidence of in-hospital adverse events, but also identifies characteristics that are strongly correlated with the risk of LVEF ≤ 50% and death after pPCI.

The effects of different doses of atorvastatin on serum lipid profile, glycemic control, and liver enzymes in patients with ischemic cerebrovascular accident.

BACKGROUND: Despite established effects of atorvastatin on level of serum lipid profile in patients with different underlying clinical conditions, the effects of this drug on other serum biomarkers remain uncertain. We examined the effects of atorvastatin therapy on lipid profile, glycemic control, and liver enzymes in patients with ischemic cerebrovascular accident without any history or clinical evidences of diabetes, heart failure, renal failure, or hepatic disease. METHODS: In a randomized double-blinded controlled trial, 140 hospitalized patients with an ischemic cerebrovascular accident were included and randomly assigned to receive either atorvastatin 40 mg (n = 70) or atorvastatin 20 mg daily (n = 70) for 3 months. The levels of biomarkers were measured at the time of administrating drugs as well as at the time of completing the treatment. RESULTS: A significant reduction was revealed in serum triglyceride, total cholesterol, low-density lipoprotein, non-high-density lipoprotein (HDL) cholesterol, and also aspartate aminotransferase levels as well as a significant increase in serum HDL level following administration of atorvastatin in both case and control groups who received the atorvastatin 40 mg/day and 20 mg/day, respectively (all P < 0.050). Although a significant increase in fasting blood sugar and hemoglobin A1c was observed in the case group received atorvastatin 40 mg/day (both P < 0.001), but this elevation was not occurred in another group treated with lower dose of the drug (both P > 0.050). CONCLUSION: Daily administration of 20 mg and 40 mg doses of atorvastatin for 3 months provides improvement in serum lipid profiles; however, because of interfering effect of high-dose atorvastatin on glycemic control status, the use of the former dose may be preferred. This is very important in these patients because the positive effects of high-dose atorvastatin in stroke patients are not confirmed.

Thrombolytic-plus-Anticoagulant Therapy versus Anticoagulant-Alone Therapy in Submassive Pulmonary Thromboembolism (TVASPE Study): A Randomized Clinical Trial.

BACKGROUND: The use of thrombolytic agents in the treatment of hemodynamically stable patients with acute submassive pulmonary embolism (PTE) remains controversial. We, therefore, conducted this study to compare the effect of thrombolytic plus anticoagulation versus anticoagulation alone on early death and adverse outcome following submassive PTE. METHODS: We conducted a study of patients with acute pulmonary embolism and pulmonary hypertension or right ventricular dilatation/dysfunction but without arterial hypotension or shock. The patients were randomly assigned in a single-blind fashion to receive an anticoagulant [Enoxaparin (1 mg/kg twice a day)] plus a thrombolytic [Alteplase (100 mg) or Streptokinase (1500000 u/2 hours)] or an anticoagulant [Enoxaparin (1 mg/kg twice a day)] alone. The primary endpoint was in-hospital death or clinical deterioration requiring an escalation of treatment. The secondary endpoints of the study were major bleeding, pulmonary hypertension, right ventricular dilatation at the end of the first week, and exertional dyspnea at the end of the first month. RESULTS: Of 50 patients enrolled, 25 patients were randomly assigned to receive an anticoagulant plus a thrombolytic and the other 25 patients were given an anticoagulant alone. The incidence of the primary endpoints was significantly higher in the anticoagulant-alone group than in the thrombolytic-plus-anticoagulant group (p value = 0.022). At the time of discharge, pulmonary artery pressure was significantly higher in the anticoagulant-alone group than in the thrombolytic-plus-anticoagulant group (p value = 0.018); however, reduction in the right ventricular size or normalization of the right ventricle showed non-significant differences between the two groups. There was no significant difference regarding the New York Heat Association (NYHA) functional class between the two groups at the end of the first month (p value = 0.213). No fatal bleeding or cerebral bleeding occurred in the patients receiving an anticoagulant plus a thrombolytic. CONCLUSION: When given in conjunction with anticoagulants, thrombolytics may improve the clinical course of stable patients who have acute submassive pulmonary embolism and prevent clinical deterioration.

Risk of sudden cardiac death.

BACKGROUND: The aim of this study was to determine characteristics of patients with sudden cardiac arrest (SCA) and/or sudden cardiac death (SCD). We need an effective risk stratification method for SCD in patients without low left ventricular ejection fraction (LVEF). METHODS: The study population of this cross-sectional study consisted of 241 patients with SCA or SCD who were admitted to an academic hospital, in Tehran, Iran, from 2011 through 2012. SCD was defined as unexpected death from cardiac causes, heralded by abrupt loss of consciousness within one hour of the onset of acute changes in cardiovascular status, or an unobserved death in which the patient was seen and known to be doing well within the previous 24 hours. Survivors of aborted SCD were also included in the study. Clinical and paraclinical characteristics as well as emergency department complications of patients were recorded. RESULTS: The mean age of population was 66.0 ± 16.5 (17 to 90 years). Among the patients, 166 (68.9 %) were male, 50 (20.7%) were smoker, 77 (32.0%) had hypertension, 47 (19.5%) had diabetes mellitus, 21 (8.7%) had hyperlipidemia, and 32 (13.3%) had renal insufficiency. According to New York Health Association (NYHA) functional class, 31 (12.9%) patients were asymptomatic, 42 (17.4) and 99 (41.1%) subjects were in NYHA I and II, respectively and only 69 (28.6%) patients were in NYHA III or IV. In this study, presenting arrhythmia was pulseless electrical activity or asystole which was observed in 130 (53.9%) subjects. Ventricular tachycardia (VT) or ventricular fibrillation (VF) was seen in 53 (22%) patients. Cardiopulmonary resuscitation in emergency room was successful only in 46 (19.1%) subjects. CONCLUSION: Low ejection fraction (EF) may be an independent predictor of sudden cardiac death in patients, but it is not enough. While implantable cardioverter defibrillators can save lives, we are lacking effective risk stratification and prevention methods for the majority of patients without low EF who will experience SCD.

Corrected thrombolysis in myocardial infarction frame count and ejection fraction in patients undergoing primary percutaneous coronary intervention for myocardial infarction.

BACKGROUND: This study aimed to assess the associations between corrected thrombolysis in myocardial infarction frame count (CTFC) of the infarct-related artery (IRA) and ejection fraction (EF) after three-six months in patients who underwent primary percutaneous coronary intervention (PPCI) for ST segment elevation myocardial infarction (STEMI). METHODS: CTFC was determined by a digital system for 78 patients. EF was measured through Simpson's method upon discharge and three-six months later. The subjects were divided into two groups of CTFC ≤ 20 (n = 54) and CTFC > 20 (n = 24). Association between CTFC and EF were then specified. RESULTS: CTFC ≤ 20 and CTFC > 20 were present in 69.2% and 30.8% of the patients, respectively. There was no significant difference between the two groups regarding baseline characteristics. EF at the time of discharge was 42.1% ± 10.2% and 43.5% ± 11.4% in groups with CTFC ≤ 20 and > 20, respectively. There was no significant association between EF at discharge and CTFC (P = 0.611). After three months, EF changed to 49.6% ± 8.7% and 41.6 ± 12.4% in the groups with CTFC ≤ 20 and CTFC > 20, respectively. Three months after PPCI, EF and CTFC had a significant relation (P = 0.007). Cumulative number and percentage of shock and death were 3 (3.8%) and 2 (2.6%), respectively. CONCLUSION: Lower CTFC of the infarct-related artery in patients undergoing PPCI for STEMI was associated with higher left ventricular ejection fraction after three months.

Premature coronary heart disease and traditional risk factors-can we do better?

BACKGROUND: Traditional cardiovascular risk factors are strong predictors of an increased likelihood for premature CHD. Considering the benefits of risk factors᾿ management, it is imperative to find and treat them before looking for more unknown and weak risk factors. OBJECTIVES: Limited information is available about the demographic and historical characteristics of the patients with premature Coronary Heart Disease (CHD) in IR Iran. The main objective of this study was to determine the prevalence of the traditional risk factors in these patients. Also, the researchers hypothesized that there are insufficient risk assessment and preventive intervention methods for the asymptomatic adult population. METHODS: This study was conducted on 125 patients with premature CHD (age<50 years) who were admitted in two academic hospitals with acute coronary syndromes. The patients were accepted since they had a definite CHD on the basis of acute myocardial infarction (elevated cardiac enzymes) or documented CAD in coronary angiography. RESULTS: The mean age of the study population was 42.50±5.65 (26 to 49 years). Among the patients,92 (73.6%) were male, 113 (90.4%) were married, 58 (46.4%) were smokers,19 (15.2%) were opium users, 97 (77.6%) had dyslipidemia, 44 (35.2%) had hypertension, and 33 (26.4%) had diabetes mellitus. In addition, family history was presented in 54 patients (43.2%). Among the study population, 120 patients (96%) had at least one of the traditional risk factors, including dyslipidemia, hypertension, diabetes mellitus, cigarette smoking, and family history of CHD. However, none of the dyslipidemic patients had controlled total cholesterol, LDL, HDL, and triglyceride. Also, none of the diabetic patients had hemoglobin A1C<7%. Among the 44 hypertensive patients, blood pressure of 15 ones (34%) was within the normal range. Besides, only 3 patients (2.4%) had regular physical activity (at least 30 minutes, three times a week). CONCLUSIONS: Premature Coronary Heart Disease is a public health problem. However, there is lack of effective and intensive treatments of well-defined traditional risk factors and prevention methods for the majority of the patients experiencing premature CHD. In sum, there is still plenty of room for improvement of risk management in IR Iran.