Comparing efficacy of receiving different dosages of eptifibatide in bleeding after percutaneous coronary intervention in patients with myocardial infarction.

BACKGROUND: Acute coronary syndrome (ACS) is a common condition that needs appropriate treatment like percutaneous coronary intervention (PCI). Glycoprotein IIb/IIIa inhibitors (GPI) like eptifibatide prevent procedural ischemic complications after PCI. Eptifibatide has increased the risk of bleeding complications, although it is effective in reducing mortality and morbidity. Eptifibatide is routinely used in bolus and infusion forms and the aim of this study is to evaluate the efficacy of bolus-only dose and bolus + infusion strategy for administrating eptifibatide in bleeding complications and consequences after PCI. METHODS: This randomized clinical trial was conducted on subjects who experienced PCI after incidence of myocardial infarction (MI). Patients were randomly divided into two groups who received bolus-only dose (n = 51) or bolus + infusion form of eptifibatide (n = 50). Then, PCI blood pressure, mean time duration of hemostasis after arterial sheath removal, laboratory data, need for blood transfusion, and presence of bleeding complications were evaluated. After 6 months, patients were followed for needs for additional coronary interventions. RESULTS: The mean age of participants was 61.68 ± 1.50 years. The prevalence of men was 70.29%. There was no significant difference in mean of systolic blood pressure (SBP) and diastolic blood pressure (DBP) during hospitalization (P > 0.050). The mean time duration of hemostasis was 8.13 ± 0.45 minutes in the bolus-only group and 16.46 ± 0.71 minutes in the bolus + infusion group (P < 0.001). There was no significant difference in the hemoglobin (Hb) level, platelet count, white blood cell (WBC), blood urea nitrogen (BUN), and creatinine level (P > 0.050). CONCLUSION: The results of this study suggested that bolus-only dose of eptifibatide before PCI could be able to decrease significantly bleeding complication and other clinical and cardiovascular outcomes.

Carotid arterial stent implantation follow-up and results in 50 patients: preliminary report.

BACKGROUND: Carotid artery stenting (CAS) is considered as a safe and effective procedure for treatment of carotid artery stenosis. Evaluation of this procedure's complications is essential for proper clinical decision-making. OBJECTIVE: This study aimed to evaluate the cardiovascular events after CAS among our patients in Isfahan, Iran. METHODS: This case-series study was conducted on fifty patients from December 2013 to May 2016. These patients were referred to the cardiology centers of Isfahan, Iran by a neurologist, for stenting of extracranial carotid arteries. The second step was examining the patients by cardiac interventionist. Stenting was performed on symptomatic patients with carotid artery stenosis of more than 50 percent or asymptomatic patients with more than 70 percent carotid artery stenosis on Doppler ultrasonography. Neurologic evaluation was performed at baseline, during hospital stay, and follow-up. Transient ischemic attack (TIA)/Stroke and Myocardial infarction (MI) questionnaires were filled out by a cardiologist over telephone interviews with the patients, for follow-up of one month, six months and at the end of study. Carotid Doppler ultrasonography was performed before and 6 months after stenting for evaluation of restenosis. Indeed, during the follow-up study, the major adverse cardiac events (MACE) were evaluated. All data were analyzed through SPSS v.17. RESULTS: The mean age of patients was 70.73 (±14.01) years old (range: 48-89 years old). Composite endpoint of death, stroke, and MI was totally 8 percent. The rate of carotid arterial restenosis (Luminal arterial narrowing>50%) was 8%. CONCLUSIONS: Despite the fact that carotid stenting is new in our center, our results can be compared to other important studies.

Compare Complication of Classic versus Patent Hemostasis in Transradial Coronary Angiography.

BACKGROUND: Coronary artery disease (CAD) is multifactorial disease, in which thrombotic occlusion and calcification occur usually. New strategies have been made for diagnosis and treatment of CAD, such as transradial catheterization. Hemostasis could be done in two approaches: traditional and patent. Our aim is to find the best approach with lowest complication. MATERIALS AND METHODS: In a comparative study, 120 patients were recruited and divided randomly into two subgroups, including traditional group (60 patients; 24 females, 36 males; mean age: 64.35 ± 10.56 years) and patent group (60 patients; 28 females, 32 males; mean age: 60.15 ± 8.92 years). All demographic data including age, gender, body mass index, and CAD-related risk factors (smoking, diabetes, hypertension) and technical data including the number of catheters, procedure duration, and hemostatic compression time and clinical outcomes (radial artery occlusion [RAO], hematoma, bleeding) were collected. Data were analyzed by SPSS version 16. RESULTS: Our findings revealed that the incidence of RAO was significantly lower in patent groups compared with traditional group (P = 0.041). Furthermore, the difference incidence of RAO was higher in early occlusion compare with late one (P = 0.041). Moreover, there were significant relationship between some factors in patients of traditional group with occlusion (gender [P = 0.038], age [P = 0.031], diabetes mellitus [P = 0.043], hemostatic compression time [P = 0.036]) as well as in patent group (age [P = 0.009], hypertension [P = 0.035]). CONCLUSION: Our findings showed that RAO, especially type early is significantly lower in patent method compared classic method; and patent hemostasis is the safest method and good alternative for classical method.

The effect of low dose versus standard dose of arterial heparin on vascular complications following transradial coronary angiography: Randomized controlled clinical trial.

BACKGROUND: The potential risk of vascular complications associated with heparin, the dose of heparin therapy has not been exactly examined in patients undergoing transradial angiography. Thus, this study was aimed to compare referral arterial thrombosis, hematoma and hemorrhagic complications with 2500 and 5000 IU arterial heparin and the association of these complications with predictors in patients undergoing diagnostic angiography. METHODS: This prospective, randomized, double-blind controlled trial was carried out on 441 patients aged ≥ 18-year-old in Isfahan, Iran. They were referred for diagnostic coronary angiography with radial access. First participants were randomized into to inject either 2500 IU (group A) or 5000 IU (group B) of heparin. Study's primary endpoints were thrombosis, hematoma, and hemorrhage. RESULTS: The frequency of thrombosis was 25.5% in group A vs. 2.3% in group B (P < 0.001), while the frequency of hematoma had no significant differences in group A and B. None of patients in both groups had hemorrhage. Using 5000 IU of heparin protected the occurrence of thrombosis by 95% [odds ratio (OR): 0.05, 95% confidence interval (CI): 0.02-012] after adjustment for confounders. CONCLUSION: The low dose (2500 IU) versus standard dose (5000 IU) of heparin use increased the risk of thrombosis following trans-radial diagnostic coronary angiography, with no effect on hematoma and bleeding.

Silymarin for the Prevention of Contrast-Induced Nephropathy: A Placebo-Controlled Clinical Trial.

BACKGROUND: Silymarin is a flavonoid complex with nephro-protective properties. We evaluated the efficacy of silymarin in the prevention of contrast-induced nephropathy (CIN). METHODS: This placebo-controlled clinical trial was conducted on 143 patients with chronic stable angina referring for elective coronary angiography. Patients with low to moderate risk for CIN were included and were randomized to receive silymarin (280 mg) or placebo 2 h before administration of the contrast material. A nonionic, iso-osmolar contrast material was used. Serum creatinine was measured before and 48 h after injection of the contrast material. CIN was defined as an increase in creatinine of ≥0.5 mg/dL or ≥25% from the baseline. RESULTS: Serum creatinine was increased by 0.02 ± 0.07 mg/dL (P = 0.004) with silymarin and by 0.04 ± 0.15 mg/dL (P = 0.008) with placebo after contrast material injection (between group difference = 0.01 ± 0.02 mg/dL, P = 0.881). CIN was occurred less frequently, though statistically nonsignificant, with silymarin compared with placebo (2.9% vs. 10.8%, Odds ratio [OR] [95% confidence interval (CI)] = 0.246 [0.050-1.203], P = 0.099). In the logistic regression analysis controlling for patients characteristics and baseline creatinine level, silymarin was nonsignificantly associated with lower frequency of CIN (OR [95% CI] = 0.203 [0.037-1.117], P = 0.067). CONCLUSIONS: We found a trend toward the efficacy of silymarin in preventing contrast-induced renal dysfunction. Further trials with larger sample size and in patients with higher risk of CIN are warranted.

Obstructive sleep apnea, diagnosed by the Berlin questionnaire and association with coronary artery disease severity.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) is a highly prevalent sleep-related disorder that is associated with increased risk of hypertension (HTN) and coronary heart disease. This study aimed to evaluate the correlation between the OSAS and coronary artery disease (CAD) severity. METHODS: The cross-sectional study was conducted from September 2012 to December 2013. We enrolled 127 patients with chronic stable angina who were referred for coronary angiographic studies in Shahid Chamran and Nour Hospitals in Isfahan, Iran. The Berlin questionnaire (BQ) was used for estimate the probability of OSAS in patients as a low or high probability. Demographic characteristics and metabolic risk factors including diabetes mellitus, HTN, obesity, and smoking also were recorded. The severity of CAD was assessed and compared based on the Gensini score with Mann-Whitney U statistical test. Independent t-test for continuous variables and chi-square test for categorical variables were used. RESULTS: Totally, 65.4% of subjects were considered as high and 34.6% as low probability for OSAS, which 81.1% of them had CAD. There was a significant difference between body mass index, systolic blood pressure, diastolic blood pressure, and ischemic heart disease drug consumption with OSAS probability (P < 0.0500). CAD was accompanied by OSAS significantly (P = 0.0260). The Gensini score was significantly higher in patients with high OSAS probability (100.4 ± 69.1 vs. 65.3 ± 68.9; P = 0.0030). OSAS also increase odds of CAD based on regression analysis (odds ratio, 95% confidence interval = 2.7). CONCLUSION: This study indicates that more severe CAD is associated with high OSAS probability identified by BQ.

Atorvastatin and prevention of contrast induced nephropathy following coronary angiography.

BACKGROUND: Contrast induced nephropathy (CIN) is one of the most common complications after radiographic procedures using intravascular radiocontrast media. The aim of the current study was to assess the effect of atorvastatin on prevention of CIN in patients undergoing coronary angiography. MATERIALS AND METHODS: In a clinical trial study, 200 patients referred for angiography were randomly divided into two groups of using 80 mg atorvastatin and placebo before the procedure. Furthermore, 100 patients who were under chronic treatment of statins were included as the third group. Serum creatinine (Scr) levels before and after the procedure were evaluated and incidence of CIN (post-procedural Scr of >0.5 mg/dl or >25% from baseline) was assessed. RESULTS: Mean age of the participants was 60.06 ± 0.69 years and 276 (92%) were male. There were no significant differences between group with respect to age and gender. In pre-operation atorvastatin, placebo and long term statin groups, the incidence of CIN was 1%, 2% and 1%, and mean changes of Glomerular filtration rate (GFR) was 3.68 ± 1.32, -0.77 ± 1.21 and 1.37 ± 0.86; and mean changes of creatinine (Cr) was -0.05 ± 0.02, 0.02 ± 0.02 and -0.01 ± 0.01 respectively. (P = 0.776, 0.026 and 0.041 respectively). In pre-operation atorvastatin group, Cr decreased, and GFR increased significantly (P = 0.019 and 0.007 respectively). CONCLUSION: pre-operation short term high dose atorvastatin use was associated with a significant decrease in serum Cr level and increase in GFR after angiography.

Perspective on the hospital incidence rate of deep venous coagulopathy: Clinical and biochemical diagnostic markers.

BACKGROUND: Identifying factors contributing to the increased risk of deep venous thrombosis (DVT) in each population is vital, because of its life-threatening outcome. The current study aims to find the diagnostic performance of some laboratory coagulation markers for predicting DVT in an Iranian population complaining of DVT in the lower limbs. PATIENTS AND METHODS: For this study, 66 consecutive patients with documented DVT, admitted to the Al-Zahra Hospital in Isfahan for the first time, were considered as the case group and 33 patients without DVT documentations were included as the control group. DVT was considered when there was visualization of thrombus or non-compressibility of the vein, confirmed by bilateral lower extremity compression Doppler ultrasonographic examination. Homocysteine, antiphospholipid, and anticardiolipin antibodies were measured in both groups by using sensitive ELISA kits. Protein C was measured via a functional clotting method, and prothrombin was measured by a kinetic, enzymatic assay. RESULTS: Multivariable analysis showed that the serum homocysteine levels was potentially associated with the presence of DVT after adjusting for age and gender (OR: 1.038, 95% CI: 1.007-1.070, P = 0.017). Comparison of the C statistic showed a partially good discrimination of homocysteine for DVT, with the area under the receiver operating characteristic (ROC) curve being 0.614 and with the optimal cut-off value of 16.5 micromol/L (µmol/L) for men and 14.5 µmol/L for women. CONCLUSION: Hyperhomocysteinemia could be considered as an independent risk factor for DVT, with an actual acceptable prognostic value, in the Iran population.

The correlation between early complications of percutaneous coronary intervention and high sensitive C-reactive protein.

BACKGROUND: Increased incidence of cardiovascular diseases, especially coronary artery disease (CAD), during recent decades shows this disease entity to be the leading cause of death in the world. On the other hand many successes were achieved in the treatment of these diseases with new technology, which has its own side effects and threats for the patient. Among these new strategies is percutaneous coronary intervention (PCI), especially with stent implantation. Although coronary stents are effective in the treatment of dissection and prevention of restenosis, many side effects and even death have been observed, from 5-10% per year. Some studies showed that there is a relation between high sensitivity C-reactive protein (hs-CRP), as a laboratory marker for early detection of thrombosis and/or restenosis, and early complications of percutaneous coronary intervention. The aim of this study is to evaluate hs-CRP level in patients after PCI and to investigate if this can be a prognostic value for detection of early complication. METHODS: This is a descriptive, analytical study done in Shahid Chamran Hospital (Isfahan, Iran) in 2011-2012. 87 patients who had undergone PCI were studied. Their hs-CRP level was measured before and after the study. Moreover, early stent complications were detected during the first 24 hours after insertion. The data was recorded in a researcher-constructed checklist and analyzed by SPSS for Windows 20. RESULTS: The mean ± SD of hs-CRP level in patients with and without complication were 1.36 ± 0.97 and 3.09 ± 1.8, respectively. According to Student's t-test, the hs-CRP level in patients with early complications was higher than patients without early complications of stent implantation; the difference was statistically significant (P < 0.001). CONCLUSION: The hs-CRP serum concentrations of patients with, and without early stent complications were significantly different. According to the control diseases center (CDC) guideline, patients with a high level of hs-CRP need special care and attention.

The impact of generic form of Clopidogrel on cardiovascular events in patients with coronary artery stent: results of the OPCES study.

BACKGROUND: To compare the early and late cardiovascular events as well as side effects of Osvix, a generic form of Clopidogrel versus Plavix regimens in patients with chronic stable angina, undergoing bare metal stent (BMS) or drug eluting stent (DES) placement, this study was carried out. METHODS: A total of 442 patients with chronic stable angina who were scheduled for elective percutaneous coronary intervention (PCI) were included in a randomized, double blind, multi-centric clinical trial being performed in 6 distinct university hospitals in 5 cities of Iran from March 2007 to November 2009. Baseline, demographic and history of risk factors were recorded using the patients' medical charts. Stenting procedure was performed via transfemoral approach using low osmolar contrast agents. Patients underwent BMS or DES placements based on the physician selection and were randomly assigned to Osvix or Plavix groups. Patients were followed by telephone in 0 and 6 months intervals regarding the major adverse cardiovascular events (MACE) including death, myocardial infarction, in-stent thrombosis, stroke, target lesion revascularization, and target vascular revascularization. Angina episodes, bleeding, liver enzymes, neutrophils and platelets count were also assessed in these intervals. RESULTS: There was not any significant difference between these two groups regarding the baseline characteristics. In the DES group, the 6-month mortality rate and the incidence of MACE in Osvix and Plavix groups were 0.9% and 1.9% (p = 0.61) and 1.8% and 4.9% (p = 0.26), respectively. During the follow up period after DES or BMS placement, there wasn't any significant difference regarding neutrophil and platelet counts or liver enzymes between study groups. CONCLUSIONS: Using Osvix and Plavix are followed by similar major cardiovascular events and side-effect profile in patients undergoing PCI.

Can doubling the maintenance dose of clopidogrel prevent from early stent thrombosis after the primary percutaneous coronary intervention?

BACKGROUND: Treatment of significant coronary artery disease with primary percutaneous coronary intervention (PCI) seems better than angioplasty balloon; because the incidence of restenosis is lower in this method, however, a serious complication of PCI is stent thrombosis which would lead to repeated myocardial infarction (MI) and increase the mortality and morbidity. One of the frequent medications which is used to prevent from stent thrombosis is clopidogrel, but, stent thrombosis was seen in many of the patients despite given the conventional dosage of this drug. This study aimed to evaluate the effect of doubling the maintenance dose of clopidogrel to prevent from early stent thrombosis, MI and mortality rate. METHODS: This was a clinical trial study which was done in Shahid Chamran Hospital in winter 2010 in Isfahan, Iran. A total of 400 patients with PCI were prospectively followed-up for 30 days. All the patients were randomly allocated into two groups. The control group received a maintenance dose of 75 mg clopidogrel while the case group received 150 mg clopidogrel after the initial dosage of 600 mg for 30 days after the PCI. The incidence of primary outcome such as total mortality was recorded during the study. RESULTS: Early stent thrombosis was observed in 4 patients (1%) (One subject in the control group and 3 in the case group) during the first 30 days after PCI, but the difference was not significant between the two groups (P=0.62). Mortality due to stent thrombosis occurred in 2 patients in the case group which showed no significant difference in this group (P=0.5). In addition, MI occurred in 2 patients (1 in each group) which also showed no significant difference between the two groups (P=1). Drug complication such as major bleeding had no significant difference between the two groups (P=0.9). CONCLUSION: The present study showed that doubling dose of clopidogrel could not reduce the incidence of early stent thrombosis, mortality and myocardial infarction in comparison with conventional dosage; therefore it is recommended that more studies be done in Iranian and Asian race for clinical decision-making to prevent form stent thrombosis using high dose of clopidogrel.

The Relation Between Ankle-Brachial Index (ABI) and Coronary Artery Disease Severity and Risk Factors: An Angiographic Study.

BACKGROUND: The current study aims to determine the relation between ankle-brachial index (ABI) and angiographic findings and major cardiovascular risk factors in patients with suspected coronary artery diseases (CAD) in Isfahan. METHODS: In this cross-sectional descriptive-analytic research, patients with suspected CAD were studied. Characteristics of studied subjects including demographics, familial history, past medical history and atherosclerotic risk factors such as diabetes mellitus, hypertension, hyperlipidemia and smoking were obtained using a standard questionnaire. ABI was measured in all studied patients. ABI≤0.9 (ABI(+)) was considered as peripheral vessel disease and ABI>0.9 (ABI(-)) was considered as normal. Then, all studied patients underwent coronary artery angiography. The results of the questionnaire and angiographic findings were compared in ABI(+) and ABI(-) groups. Data were analyzed by SPSS 15 using ANOVA, t-test, Spearman's rank correlation coefficient, and discriminant analysis. RESULTS: In this study, 125 patients were investigated. ABI≤0.9 was seen in 25 patients (20%). The prevalence of ABI(+) among men and women was 25.9% and 7.5%, respectively (P=0.01). The prevalence of atherosclerotic risk factors was significantly higher in ABI(+) patients than in ABI(-) ones (P<0.05). ABI(+) patients had more significant stenosis than ABI(-) ones. The mean of occlusion was significantly higher in ABI(+) patients with left main artery (LMA), right coronary artery (RCA), left anterior descending artery (LAD), diagonal artery 1 (D1) and left circumflex artery (LCX) involvements (P<0.05). CONCLUSION: The findings of this research indicated that ABI could be a useful method in assessing both the atherosclerotic risk factors and the degree of coronary involvements in suspected patients. However, in order to make more accurate decisions for using this method in diagnosing and preventing CAD, we should plan further studies in large sample sizes of general population.

The predictive factors of recurrent deep vein thrombosis.

BACKGROUND: About 2-5% of people experience deep-vein thrombosis (DVT) during their lives. Death, disease recurrence, post-thrombotic syndrome, and excessive bleeding due to coagulant medications are among the most important DVT complications. Recent research found a high incidence of DVT recurrence after the first attack. Disease recurrence has a multifactorial pathogenesis and its probability is related with the number and severity of risk factors. The present study aimed to investigate DVT recurrence and the associated risk factors. METHODS: This retrospective cross-sectional study evaluated all DVT patients hospitalized in Alzahra Hospital, Isfahan, Iran, during April 2000 to April 2011. The risk factors were obtained from patients' records including smoking, intravenous drug abuse, having a history of surgery in last four weeks, immobility, obesity, history of cardiac disease, and cancer. RESULTS: A total number of 2550 DVT patients were hospitalized in Alzahra Hospital during the study period. It was only possible to extract the data from 385 patient records. A history of DVT was reported in 48 individuals (12.5%). The comparison between the risk factors in patients with a first time DVT and those experiencing a recurrent DVT revealed significant differences solely in the prevalence of blood disorders and immobility. Applying stepwise regression indicated immobility (OR: 4.57; 95% CI: 1.26-16.57; P < 0.021) and coagulopathy (OR: 0.33; 95% CI: 0.13-0.81; P < 0.016) with DVT recurrence. CONCLUSION: Based on our findings, DVT patients are suggested to be mobilized as soon as possible. In addition, they should be advised to increase their activity after discharge.