Heart failure: a prevalence-based and model-based cost analysis.

Introduction: Heart failure (HF) imposes a heavy economic burden on patients, their families, and society as a whole. Therefore, it is crucial to quantify the impact and dimensions of the disease in order to prioritize and allocate resources effectively. Methods: This study utilized a prevalence-based, bottom-up, and incidence-based Markov model to assess the cost of illness. A total of 502 HF patients (classes I-IV) were recruited from Madani Hospital in Tabriz between May and October 2022. Patients were followed up every two months for a minimum of two and a maximum of six months using a person-month measurement approach. The perspective of the study was societal, and both direct and indirect costs were estimated. Indirect costs were calculated using the Human Capital (HC) method. A two-part regression model, consisting of the Generalized Linear Model (GLM) and Probit model, was used to analyze the relationship between HF costs and clinical and demographic variables. Results: The total cost per patient in one year was 261,409,854.9 Tomans (21,967.21 PPP). Of this amount, 207,147,805.8 Tomans (17,407.38 PPP) (79%) were indirect costs, while 54,262,049.09 Tomans (4,559.84 PPP) (21%) were direct costs. The mean lifetime cost was 2,173,961,178 Tomans. Premature death accounted for the highest share of lifetime costs (48%), while class III HF had the lowest share (2%). Gender, having basic insurance, and disease class significantly influenced the costs of HF, while comorbidity and age did not have a significant impact. The predicted amount closely matched the observed amount, indicating good predictive power. Conclusion: This study revealed that HF places a significant economic burden on patients in terms of both direct and indirect costs. The substantial contribution of indirect costs, which reflect the impact of the disease on other sectors of the economy, highlights the importance of unpaid work. Given the significant variation in HF costs among assessed variables, social and financial support systems should consider these variations to provide efficient and fair support to HF patients.

Effects of Triamterene in Hospitalized Patients with Heart Failure and Diuretic Resistance: A Randomized Clinical Trial.

Due to the potential benefits of triamterene in diuretic resistance, this study was performed to assess whether triamterene add-on to the standard treatment of heart failure (HF)-related diuretic resistance improves outcomes. A randomized clinical trial was performed on 45 hospitalized patients with HF with reduced ejection fraction who had diuretic resistance. Patients were randomized to receive either triamterene 50 mg plus hydrochlorothiazide 25 mg (n = 23) or hydrochlorothiazide 50 mg alone (n = 22) until hospital discharge. The primary outcomes were changes in weight and fluid input-to-output ratio. Secondary outcomes were respiratory rate, hospitalization duration, serum sodium and potassium, estimated glomerular filtration rate, creatinine, and blood urea nitrogen levels during the study period. The mean (standard deviation) of weight changes was not significantly different in the intervention and the control groups (-6.3 [4.8] vs -4.8 [2.4] kg, respectively; P = .1). No significant differences were shown in input-to-output changes between the 2 groups (208.0 [243.4] in the intervention and 600.2 [250.3] in the control group; P = .4). Although the respiratory rate of triamterene-treated patients decreased, the difference did not reach statistical significance (P = .2). Other secondary outcomes were also similar in both groups. This study did not support the use of triamterene as an add-on therapy for patients with HF-related diuretic resistance.

Clinical utility of aVR lead T-wave in electrocardiogram of patients with ST-elevation myocardial infarction.

BACKGROUND: aVR lead is often neglected in routine clinical practice largely because of its undefined clinical utility specifications. Nevertheless, positive T-wave in aVR lead has been reported to be associated with poor clinical outcomes in some cardiovascular diseases. This study aimed to prospectively investigate the prognostic value and clinical utility of T-wave amplitude in aVR lead in patients with acute ST-elevation myocardial infarction (STEMI). METHODS: A total of 340 STEMI patients admitted to a tertiary heart center were consecutively included. Patients were categorized into four strata, based on T wave amplitude in aVR lead in their admission ECG (i.e. < - 2, - 1 to - 2, - 1 to 0, and ≥ 0 mV). Patients' clinical outcomes were also recorded and statistically analyzed. RESULTS: In-hospital mortality, re-hospitalization, and six-month-mortality significantly varied among four T wave strata and were higher in patients with a T wave amplitude of ≥ 0 mV (p 0.001-0.002). The groups of patients with higher T wave amplitude in aVR, had progressively increased relative risk (RR) of in-hospital mortality (RRs ≤ 0.01, 0.07, 1.00, 2.30 in four T wave strata, respectively). T wave amplitude in the cutoff point of - 1 mV exhibited a sensitivity and specificity of 95.83 (95% CI 78.88-99.89) and 49.68 (95% CI 44.04-55.33). CONCLUSION: Our study demonstrated a significant association of positive T wave in aVR lead and adverse clinical outcomes in STEMI patients. Nevertheless, the clinical utility of T-wave amplitude at aVR lead is limited by its low discriminative potential toward prognosis of STEMI.

Cost-effectiveness analysis of lung cancer screening with low-dose computed tomography in an Iranian high-risk population.

OBJECTIVE: The results of recent studies have shown that using low-dose computed tomography (LDCT) for screening of lung cancer (LC) improves cancer outcomes. The objective of the current study was to evaluate the cost-effectiveness of LDCT in an Iranian high-risk population. METHODS: A Markov cohort simulation model with four health states was used to evaluate the cost-effectiveness of LDCT from a healthcare system perspective in the people aged 55-74 who smoked 25 or more cigarettes per day for 10-30 years. Cost data were collected, reviewing 324 medical records of patients with LC, and utilities and transition probabilities were extracted from the literature. The Monte Carlo simulation method was applied to run the model. Probabilistic sensitivity analysis and one-way analysis were also performed. RESULTS: LC screening in comparison to a no-screening strategy was costly and effective. The incremental cost-effectiveness ratio of screening versus no-screening was IRR (Iranian rials) 98,515,014.04 which falls below the Iranian threshold of three times GDP (gross domestic product) per capita. One-way and probabilistic sensitivity analyses demonstrated that the results of the economic analysis were robust to variations in the key inputs for both. CONCLUSIONS: Using LDCT for screening of LC patients in a high-risk population is a cost-effective strategy.

Direct and Indirect Costs Associated with Coronary Artery (Heart) Disease in Tabriz, Iran.

PURPOSE: Cardiovascular diseases (CVDs) are the major causes of mortalities worldwide. This study was conducted to evaluate the direct and indirect costs of coronary artery disease (CAD) in Iran. PATIENTS AND METHODS: This is a prevalence-based cost-of-illness (COI) study that estimates the direct and indirect costs of CAD. The study conducted over a six-month period from April to September in 2017. Patients were recruited from Madani hospital in Tabriz, Iran. A total of 379 patients were investigated from societal perspective. Direct costs were estimated using the bottom-up costing approach and indirect costs were estimated using the Human Capital (HC) approach. A generalized linear model of regression was used to explore the relation between total cost and socio-demographic variables. The total annual mean cost was compared to Gross Domestic Product (GDP) per capita which was reported in the form of Purchasing Power Parity (PPP) index. To deal with uncertainty, one-way sensitivity analysis was performed. RESULTS: Total costs per patient in one year were estimated to be IRR 63452290.17 ($PPP 7736.19) at a 95% confidence interval (58191511.73-68713068.60), the biggest part of which is related to direct medical costs with IRR 33884019.53 per year ($PPP 4131.18) (54%). Direct non-medical costs were estimated IRR 1655936.68 ($PPP 201.89) per patient (2%) and indirect costs were estimated IRR 27912333.97 per patient ($PPP 3403.11) (44%), which 62% of indirect costs is related to patients' work absenteeism. CONCLUSION: This study estimates the direct (56%) and indirect (44%) costs associated with CAD. The study explores the essential drivers of the costs and provides the magnitude of the burden in terms of the share of GDP. The outcomes can be used in priority setting, in particular for cost benefit analysis, and adopting new policies regarding insurance coverage and equity issues.

Effects of foot reflexology on anxiety and physiological parameters in patients undergoing coronary artery bypass graft surgery: A clinical trial.

INTRODUCTION: This study aimed to investigate the effect of foot reflexology on anxiety and physiological parameters in patients after CABG surgery. METHOD: This was a single-blind, three-arm, parallel-group, randomized controlled trial with three groups of 40 male patients undergoing CABG. Participants were placed in three groups, named intervention, placebo, and control. Physiological parameters were measured including systolic and diastolic blood pressure, mean arterial pressure, heart rate, respiratory rate, percutaneous oxygen saturation, and anxiety of participants. RESULTS: Results showed a statistically significant difference between intervention and control groups in terms of the level of anxiety (p < 0.05). Also, results showed a statistically significant effect on all physiological parameters except heart rate (p < 0.05). CONCLUSION: This study indicated that foot reflexology may be used by nurses as an adjunct to standard ICU care to reduce anxiety and stabilize physiological parameters such as systolic, diastolic, mean arterial pressure, and heart rate.

Comparative effect of grape seed extract (Vitis vinifera) and ascorbic acid in oxidative stress induced by on-pump coronary artery bypass surgery.

BACKGROUND: This study aimed to test the beneficial effect of grape seed extract (GSE) (Vitis vinifera) and Vitamin C in oxidative stress and reperfusion injury induced by cardiopulmonary bypass (CPB) in coronary artery bypass surgery. PATIENTS AND METHODS: In this randomized trial, 87 patients undergoing elective and isolated coronary bypass surgery included. The patients were randomly assigned into three groups (n = 29 each): (1) Control group with no treatment, (2) GSE group who received the extract 24 h before operation, 100 mg every 6 h, orally, (3) Vitamin C group who received 25 mg/kg Vitamin C through CPB during surgery. Blood samples were taken from coronary sinus at (T1) just before aortic cross clamp; (T2) just before starting controlled aortic root reperfusion; and (T3) 10 min after root reperfusion. Some clinical parameters and biochemical markers were compared among the groups. RESULTS: There were significant differences in tracheal intubation times, sinus rhythm return, and left ventricular function between treatment groups compared with control (P < 0.05). Total antioxidant capacity was higher (P < 0.05) in both grape seed and Vitamin C groups at T2 and T3 times. In reperfusion period, malondialdehyde level was increased in control group; however, it was significantly lower for the grape seed group (P = 0.04). The differences in the mean levels of superoxide dismutase and glutathione peroxidase among the three groups were not significant (P > 0.05 in all cases). CONCLUSIONS: In our patients, GSE and Vitamin C had antioxidative effects and reduced deleterious effects of CPB during coronary artery bypass grafting surgery.

Outcome of surgical embolectomy in patients with massive pulmonary embolism with and without cardiopulmonary resuscitation.

INTRODUCTION: Pulmonary embolism is a challenging critical cardiovascular disease with high morbidity and mortality. Surgical embolectomy has favorable results in patients with massive pulmonary embolism. AIM: To study the outcome of embolectomy in patients with massive pulmonary embolism. MATERIAL AND METHODS: In this single-center, retrospective study, 36 patients including 14 male and 22 female patients with a mean age of 50.80 ±18.89 years with acute pulmonary embolism who underwent surgical pulmonary embolectomy from January 2011 to January 2016 were included. The medical records of all patients were reviewed for demographic and preoperative data and postoperative outcomes. RESULTS: Common risk factors for acute PE were major surgery within 3 months and deep vein thrombosis. The most common presenting symptoms of patients were dyspnea, followed by chest pain and syncope. Mean duration of hospitalization was 14.76 ±8.69 days and mean operation duration was 4.47 ±1.54 h. Mean time from admission to embolectomy was 6.58 ±1.13 h. Ten (27.8%) patients died during the operation including 3 cases with cardiopulmonary resuscitation prior to surgery and 2 cases with severe cardiogenic shock. Patients who survived were followed for 6 months. The mortality rate during follow-up was 15.4%; all 4 patients died during follow-up period due to metastatic cancer. No pulmonary embolism recurrance were seen. CONCLUSIONS: Although surgical embolectomy mostly was done for high risk patients, it had good in-hospital and excellent mid-term outcomes.

Vasorelaxant effect of 17α-ethynylestradiol on human saphenous vein.

PURPOSE: A protective effect for estrogens against cardiovascular problems has long been known. The aim of this study was to investigate the vasorelaxant effect of 17α-Ethynylestradiol (17α-EE) on human saphenous vein. METHODS: The veins were suspended horizontally between two triangular stainless steel hooks for the measurement of isometric tension in individual organ baths containing 10ml Krebs solution, at 37°C and gassed with carbogen under 3gr optimum tension. The effect of different concentrations of 17α-EE (2-40 µM) on vascular tone was investigated in veins precontracted with PGF2α. Relaxation was measured after 40min and expressed as the percent decrease of initial contraction. To determine the involvement of potassium channels, endothelium, nitric oxide synthase, guanylylcyclase and prostaglandins in the vasorelaxant effect of estrogen, the veins were incubated with tetraethyl ammonium, N-nitro-L-arginine methyl ester, methylene blue or indomethacin, respectively for 20min prior to experimentation. Responses to 17α-EE were directly compared to those obtained in the same tissues in the absence of the inhibitors. RESULTS: The mean relaxations induced by 17α-EE with concentrations of 2, 5, 10, 20 and 40µM in tissues precontracted with PGF2α were 19.8 ±5.5%, 26.1±10.8%, 32.2±7.4%, 48.6±10.8%and56±7.6%, respectively. The results of the inhibition of potassium channels, nitric oxide synthase, guanylylcyclase, cyclooxygenase and removing endothelium in relaxation induced by 17α-EE on precontracted veins with PGF2α proved no significant differences. CONCLUSION: This study showed that 17α-EE has significant vasorelaxant effect on human saphenous vein in a concentration-dependent manner. This effect is probably independent of potassium channels, nitric oxide synthase, guanylylcyclase, prostaglandin synthesis and endothelium functions.

Rheumatic aortic regurgitation in a patient with large congenital fenestrations in all three leaflets.

Fenestrations of the aortic valve rarely produce significant valvular regurgitation. These are typically described as incidental findings with little clinical significance because they generally lie above their closing edges. Rarely however, when unusually large or multiple, they can lead to massive aortic regurgitation (AR), mostly in patients with chronic hypertension and/or aortic annular dilation. We operated a 52 year old normotensive male with chronic rheumatic AR and found large fenestrations in all three aortic cusps, hardly ever reported in rheumatic valvular involvement in the literature.

A Ball in the Heart: An Interesting Discovery in a Very RareCardiac Tumor.

Primary pericardial malignant mesothelioma is an extremely rare tumor even among all mesotheliomas with about 350 cases reported in the literature so far. Typically, it has an insidious presentation, with nonspecific signs and symptoms, and usually results in constrictive pericarditis, cardiac tamponade or congestive heart failure through either a massive effusion or direct tumurous constriction or invasion to the heart. With the exception of several case reports, the outcome is uniformly dismal and patients typically die within six months of diagnosis. We report a 24 year old male with long history of pleuretic chest paint and admissions with a diagnosis of idiopathic pericarditis, eventually presenting with increasing symptoms of heart failure and a large mobile ball like mass in the heart at echocardiographic and computed tomography studies. At operation, an atypical invasive cardiac tumor was discovered. Complete resection of the tumor was impossible and the patient died from progression of the disease 4 months later.

Idiopathic great saphenous phlebosclerosis.

Arterial sclerosis has been extensively described but reports on venous sclerosis are very sparse. Phlebosclerosis refers to the thickening and hardening of the venous wall. Despite its morphological similarities with arteriosclerosis and potential morbid consequences, phlebosclerosis has gained only little attention. We report a 72 year old male with paralysis and atrophy of the right leg due to childhood poliomyelitis who was referred for coronary artery bypass surgery. The great saphenous vein, harvested from the left leg, showed a hardened cord-like obliterated vein. Surprisingly, harvested veins from the atrophic limb were normal and successfully used for grafting.

Prophylactic high-dose oral-N-acetylcysteine does not prevent atrial fibrillation after heart surgery: a prospective double blind placebo-controlled randomized clinical trial.

AIMS: Postoperative atrial fibrillation (POAF) following cardiac surgery is a frequent complication with multifactorial etiologies. Recently inflammation due to enhanced oxidative stress has been implicated in its pathogenesis. N-acetylcysteine (NAC) is a promising and novel antioxidant agent. The purpose of this study was to evaluate the efficacy of high-dose oral-NAC for prevention of POAF. METHODS: Two hundred and forty patients were randomized in this prospective, double blind placebo-controlled trial to either 1,200-mg oral-NAC two times a day (n = 120) or placebo (n = 120) starting 48 hours before and up to 72 hours after open heart surgery. RESULTS: The mean age was about 60 years, and 75% were male. Patients in the NAC group were older, with higher percentage of acute coronary syndrome, hypercholesterolemia, and left internal mammary artery use. Coronary involvement and hypertension were more prevalent in the placebo group. All other baseline patient characteristics were similar between groups. Overall POAF developed in 13.8% of the patients. There was no difference in the incidence of POAF between the NAC vs placebo groups (11.7% vs 15.8%, respectively; P = 0.34). Postoperative hospital stay, morbidity, and mortality were similar in both groups. CONCLUSIONS: Prophylactic high-dose oral-NAC begun 2 days before open heart surgery and continued for 5 days, and had no significant effect on the incidence of POAF, in-hospital stay, and postoperative morbidity or mortality.

A unique nail gun injury to the heart with a delayed presentation.

We describe a 24-year-old construction worker who was unaware that he had been shot by a pneumatic nail gun in the chest during work. After returning home, he felt some palpitations and mild shortness of breath, and in the mirror discovered a non-bleeding pinpoint skin wound in his upper chest. He admitted himself to the emergency department of a local hospital and, after a detailed history and a chest X-ray had been taken, he was surprisingly diagnosed with a penetrating nail injury to the heart and was referred to our center. Transthoracic echocardiography and chest computed tomography were done, and the patient was transported to the operating room. After the nail had been removed and the mitral valve repaired, the patient was discharged on the fifth postoperative day without any complications.

Influence of anterior periaortic fat pad excision on incidence of postoperative atrial fibrillation.

OBJECTIVE: In humans, the existence of an anterior periaortic fat pad (AFP) containing parasympathetic ganglia has been described in the aortopulmonary window. Changes in the autonomic nervous system (ANS) tone can lead to postoperative atrial fibrillation (POAF). The AFP is usually removed during coronary bypass grafting (CABG) to fully expose the aortic root. The purpose of this study was to evaluate the influence of AFP removal during CABG on the ANS tone, incidence of POAF, hospital stay, and in-hospital morbidity and mortality. METHODS: A total of 215 patients were randomized in this prospective, double-blind trial to either removal (n=107) or maintenance (n=108) of the AFP during their first CABG. All patients underwent continuous telemetry monitoring after surgery. They underwent at least 1-h Holter monitoring on the second postoperative day. Heart rate variability measurements of both time-domain and frequency-domain analysis were included. POAF was defined as AF for more than 5min or causing hemodynamic instability. RESULTS: The mean age was nearly 58 years, and 76% were male. There was no difference in the incidence of POAF between the retained and removed AFP groups (19.3% vs 17%, respectively; P=0.664, odds ratio=1.16). Mean heart rate and heart rate variability parameters, in-hospital stay, and postoperative morbidity and mortality were similar in both groups. CONCLUSIONS: Removal of the AFP during CABG has no significant effect on the incidence of POAF, ANS tone, and postoperative morbidity or mortality.

Survey of operative outcome for aortic dissection.

OBJECTIVE: To survey the results of operative outcome for aortic dissection. METHODS: A retrospective study on 46 patients, admitted for operation in Shahid Madani Heart Hospital in Tabriz, Iran from 1994-2003. A questionnaire was used for collecting data. Statistical analysis was performed and was carried out through a descriptive statistical methods. RESULTS: We included 30 males (65%) and 16 females (35%). Seven (15.2%) died in the operating room before surgery, while 39 patients (59% male and 41% female) underwent surgery. The mean age of patients was 48.9 +/- 2.3 years old. Pre-operative diagnosis was carried out by transesophageal echocardiography and angiography. All patients were operated in an emergency situation. In 42% of patients aortic valve replacement (AVR) with ascending aorta was replaced. In 24% only the ascending aorta was replaced, and in 10% the aortic valve was repaired with acute aortic dissection. In 10% of patients, the ascending aorta with aortic arch was replaced. Four patients (14%) had distal aortic dissection and replacement. Major complications were hemorrhage (31%) and respiratory failure (13.8%). A total of 20.7% died in hospital, and only 21 patients (45.5%) could be followed for 10 years. CONCLUSION: Acute aortic dissection is a fatal disease. With early diagnosis and surgical intervention, we can save approximately 75% of patients with very good functional class and survival in the mid term.