Development of the first Iranian clinical practice guidelines for the diagnosis, treatment, and secondary prevention of acute coronary syndrome.

Background: This article introduces the first national guidelines for the management including diagnosis, treatment, and secondary prevention of acute coronary syndrome (ACS) in Iran. Materials and Methods: The members of the guideline development group (GDG) were specialists and experts in fields related to ACS and were affiliated with universities of medical sciences or scientific associations in the country. They carefully examined the evidence and clinical concerns related to ACS management and formulated 13 clinical questions that were sent to systematic review group who developed related evidence using Grade method. Finally the GDG developed the recommendations and suggestions of the guideline. Results: The first three questions in the guideline focus on providing recommendations for handling a patient who experience chest pain at home, in a health house or center, during ambulance transportation, and upon arrival at the emergency department (ED) as well as the initial diagnostic measures in the ED. Subsequently, the recommendations related to the criteria for categorizing patients into low, intermediate and high-risk groups are presented. The guideline addressed primary treatment measures for ACS patients in hospitals with and without code 247 or having primary percutaneous coronary intervention (PCI) facilities, and the appropriate timing for PCI based on the risk assessment. In addition, the most efficacious antiplatelet medications for ACS patients in the ED as well as its optimal duration of treatment are presented. The guideline details the recommendations for therapeutic interventions in patients with ACS and acute heart failure, cardiogenic shock, myocardial infarction with nonobstructive coronary arteries (MINOCA), multivessel occlusion, as well as the indication for prescribing a combined use of anticoagulants and antiplatelet during hospitalization and upon discharge. Regarding secondary prevention, while emphasizing the referral of these patients to rehabilitation centers, other interventions that include pharmaceutical and nonpharmacological ones are addressed, In addition, necessary recommendations for enhancing lifestyle and posthospital discharge pharmaceutical treatments, including their duration, are provided. There are specific recommendations and suggestions for subgroups, such as patients aged over 75 years and individuals with heart failure, diabetes, and chronic kidney disease. Conclusion: Developing guidelines for ACS diagnosis, treatment and secondary prevention according to the local context in Iran can improve the adherence of our health care providers, patients health, and policy makers plans.

The assessment of no-reflow phenomenon incidence in early versus delayed percutaneous coronary intervention following a primary fibrinolysis.

BACKGROUND: Percutaneous coronary intervention (PCI) is the gold standard approach to ST-Segment Elevation Myocardial Infarction (STEMI). Fibrinolysis followed by PCI has been recommended. The current study aims to investigate the no-reflow phenomenon incidence in patients undergoing post-thrombolytic therapy PCI. METHODS: This cross-sectional study was conducted on 250 patients with STEMI who primarily received fibrinolytic therapy followed by early (3-24 hours) (n=231) or delayed (> 24 hours) (n=19) PCI. They were also subcategorized into four intervals: <6 hours (n=98), 6-12 hours (n=93), 12-24 hours (n=38), and ≥24 hours (n=21). The demographic and medical data of the patients were retrieved. The Thrombolysis in Myocardial Infarction score (TIMI) was assessed at baseline and at the end of PCI. A TIMI score other than 3 was defined as no-reflow. RESULTS: The incidence of the no-reflow phenomenon was not associated with any of the underlying demographic and medical characteristics of the patients (P-value>0.05). Despite the significantly higher rate of improvement in TIMI grading among those undergoing early PCI (P-value=0.04), as well as within less than 6 hours after thrombolytic therapy (P-value=0.031), the rate of the no-reflow phenomenon did not differ between the groups, neither by sorting them as early versus delayed (P-value=0.518) nor by categorizing them into four intervals (P-value=0.367). CONCLUSION: Based on the findings of the current study, early PCI after fibrinolysis led to significantly improved TIMI flow. However, the incidence of no-reflow did not differ between the groups with early versus delayed post-fibrinolysis PCI.

Apixaban, a Novel Oral Anticoagulant, Use to Resolute Arterial Patency in Radial Artery Occlusion Due to Cardiac Catheterization; A Pilot Randomized Clinical Trial.

INTRODUCTION: In recent years, transradial cardiac catheterization has become the preferred method. However, it can result in a significant complication known as radial artery occlusion (RAO). The medical management of RAO remains controversial, especially with the emergence of novel oral anticoagulants. Nevertheless, there is limited data on the use of these agents for treating RAO, which is the focus of this study using apixaban. METHOD: This pilot double-blinded randomized clinical trial involved 30 patients who developed RAO following transradial coronary angiography. The patients were randomly assigned to receive either apixaban (2.5 mg twice daily) or a conservative approach for 30 days. Doppler ultrasonography was performed at baseline and at the end of the intervention to assess radial artery diameter and the resolution of arterial patency. Demographic, medical, medication, and clinical characteristics were collected. RESULTS: The mean age of the studied population was 59.43±12.14 years, and the majority were males (60%). Radial artery resolution was observed in 21 (70%) patients, independent of medication use. There was no significant association between resolution and age (P-value=0.62), gender (P-value=0.74), body mass index (P-value=0.23), smoking (P-value=0.64), diabetes (P-value=0.999), hypertension (P-value=0.74), statins (P-value=0.999), antiplatelet therapy (P-value=0.999), length of angiography (P-value=0.216), or follow-up arterial diameter (P-value=0.304). Recanalization occurred in 13 (86.7%) cases in the apixaban treatment group, compared to 8 (53.3%) individuals in the control group, indicating a significant difference (P-value=0.046). CONCLUSION: The study findings suggest no demographic, medical, medication, or clinical factors were associated with arterial recanalization. However, a one-month treatment with apixaban at a dose of 2.5 mg twice daily appeared to be effective.

Does Adjunctive Prophylactic Intracoronary Infusion of Low Dose Alteplase Prevent No-Reflow Phenomenon During Primary Percutaneous Coronary Intervention?

INTRODUCTION: Primary percutaneous coronary intervention (PPCI) is the gold standard approach to restore blood flow in ST-segment elevation myocardial infarction (STEMI); however, the no-reflow phenomenon as a potential complication of PPCI can worsen the outcomes. It has been hypothesized that adjunctive prophylactic intracoronary infusion of low-dose fibrinolytic might improve the PPCI outcomes; however, this theory is a matter of debate. The current study aims to investigate the value of adjunctive prophylactic intracoronary low-dose alteplase to prevent the no-reflow phenomenon in patients with STEMI. METHOD: This case-control study was conducted on 80 STEMI patients who underwent PPCI. The patients were assigned into the case group who were intervened by 10 mg adjunctive intracoronary alteplase immediately at the end of the balloon angioplasty (n=40) and controls (n=40) who underwent conventional PPCI only. The angioplasty-associated outcomes including final TIMI score, need for no-reflow treatment, ST-segment resolution, post-PPCI complications, and death were compared between the groups. RESULTS: Alteplase use was accompanied by significantly improved final TIMI flow scores (P-value<0.001) and fewer requirements for no-reflow treatments (P-value<0.001); however, it did not improve the ST-segment resolution (P-value=0.491). The mortality rate and post-angioplasty complications did not differ between the groups (P-value>0.05). CONCLUSION: Based on the findings of this study, adjunctive infusion of low-dose intracoronary alteplase during PPCI could not efficiently prevent the no-reflow phenomenon. Although the final TIMI flow and need for post-stenting no-reflow treatment improved, ST-segment resolution did not occur dramatically. Given that, this approach requires further investigations and should be considered cautiously.

Investigating the Prevalence of Contrast-associated Nephropathy and the Related Risk Factors in Patients Undergoing Elective Angioplasty.

Objective: Contrast-associated nephropathy (CAN) is a sudden decrease in kidney function following contrast media administration. Considering the importance of CAN in the patient's outcome and the high prevalence of this complication in cardiac catheterizing centers, this study was designed to investigate the prevalence and the related risk factors of CAN in patients undergoing angioplasty in Chamran Heart Hospital, Isfahan, Iran, from January 2022 to June 2022. Methods: The inclusion criteria were adult patients above 18 admitted for elective percutaneous coronary intervention (PCI). Patient demographic information, underlying diseases and medications, dehydration state, type and amount of contrast media, and serum levels of blood urea nitrogen (BUN) and serum creatinine (SrCr) at 24 and 72 h after contrast injection were all recorded. Findings: Out of 340, 128 patients developed CAN after PCI, giving an incidence of 37.64%. Adjusted analysis showed a significant relation between age over 65, the amount of contrast media administered, and the use of furosemide with the incidence of CAN. However, adjusted logistic regression analysis failed to show any significant relationship between the risk of CAN and the hydration status of the patients at 24 and 48 h after receiving contrast media as diagnosed by BUN/SrCr >20. Conclusion: The prevalence of CAN in this study was higher than in other studies since this high-risk population was under risk factors such as arterial injection of contrast material and a higher amount of contrast material administration. In addition, advanced age, volume of contrast material, and previous or concurrent furosemide administration were associated with an increased risk of CAN.

Survey of coronary catheterization laboratory activity in Iran during the coronavirus disease-2019 pandemic.

BACKGROUND: With the onset of the coronavirus disease-2019 (COVID-19) pandemic, hospitalization and treatment of non-covid patients decreased worldwide. The aim of this study is to evaluate the admission and treatment of patients with coronary artery diseases (CADs) by examining coronary Cath labs activities in some centers of Iran during the COVID-19 period. METHODS: A retrospective, multi-center survey was conducted in four cites in Iran which participated in National Persian Registry Of CardioVascular diseasE (N-PROVE). Two periods of COVID-19 occurrence peak in Iran were compared with the same date in 2019. Information was collected on the number of diagnostic and therapeutic coronary catheterizations in both stable ischemic heart diseases (SIHDs) and acute coronary syndrome (ACS) settings. RESULTS: In the first peak of COVID-19 pandemic, coronary angiographies and angioplasties decreased by 37 and 38% compared to the same period in 2019, respectively. The most common indication for coronary angiography during this period was ACS [especially ST-Segment Elevation Myocardial Infarction (STEMI)]; however, at the time of peak decrease, the SIHDs were the most. In the second peak of COVID-19 pandemic in Iran, 34% and 27% decrease in diagnostic and therapeutic coronary procedures were seen, respectively. During this period, the number of elective admissions increased, although it was still lower than that in 2019. The tendency to rescue percutaneous coronary intervention increased in most centers during the COVID-19 era, especially in the second peak. CONCLUSION: A significant reduction in the coronary Cath lab activity has been observed during the COVID-19 pandemic that can indicate an increased risk of cardiovascular mortality and morbidity.

Long-Term Outcome After Transcatheter Atrial Septal Defect Closure in Adults: A Systematic Review and Meta-Analysis.

AIMS: We performed a systematic review and meta-analysis of published studies to characterize the current literature and help determine the long-term outcomes after transcatheter ASD closure in adults. METHODS AND RESULTS: Two investigators searched the manuscript databases for all eligible studies in accordance with the considered keywords. The pooled prevalence of each event according to the meta-analysis and considering the weight calculated for each study included 10.1% (for arrhythmia), 1.8% (for emboli), 2.3% (for stroke), 12.5% (for residual shunt), 1.8% (for erosion), and 2.5% (for death). CONCLUSION: The present meta-analysis show high long-term successfulness of transcatheter ASD closure in adults.