Investigating the expression level of miR-17-3p, miR-101-3p, miR-335-3p, and miR-296-3p in the peripheral blood of patients with acute myocardial infarction.

The role of inflammation has been proven in acute myocardial infarction (AMI) pathogenesis. Due to the effect of NLRP3 gene expression in the inflammation process of MI, we aimed to explore the expression changes and diagnostic power of four inflammation-related miRNAs including miR-17-3p, miR-101-3p, miR-335-3p, miR-296-3p and their potential target, NLRP3, in ST-segment elevation myocardial infarction (STEMI), and non-STEMI (NSTEMI) patients as two major classes of AMI. The expression level of these genes were evaluated in 300 participants equally divided into three groups of STEMI, NSTEMI, and control using quantitative real-time PCR. The expression level of NLRP3 was upregulated in STEMI and NSTEMI patients compared to control subjects. Besides, the expression levels of miR-17-3p, miR-101-3p, and miR-296-3p were significantly downregulated in STEMI and NSTEMI patients compared to controls. The increased expression of NLRP3 had a very strong inverse correlation with miR-17-3p in patients with STEMI and with miR-101-3p in the STEMI and NSTEMI patients. ROC curve analysis showed that the expression level of miR-17-3p had the highest diagnostic power for discrimination between STEMI patients and controls. Remarkably, the combination of all markers resulted in a higher AUC. In summary, there is a significant association between the expression levels of miR-17-3p, miR-101-3p, miR-335-3p, miR-296-3p, and NLRP3 and the incidence of AMI. Although the miR-17-3p expression level has the highest diagnostic power to distinguish between STEMI patients and control subjects, the combination of these miRNAs and NLRP3 could serve as a novel potential diagnostic biomarker of STEMI.

Management of ST-segment-elevation myocardial infarction during the coronavirus disease 2019 (COVID-19) outbreak: Iranian"247" National Committee's position paper on primary percutaneous coronary intervention.

World Health Organization has designated coronavirus disease 2019 (COVID-19) as a pandemic. During the past several weeks, a considerable burden has been imposed on the Iranian's healthcare system. The present document reviewed the latest evidence and expert opinion regarding the management of ST-segment-elevation myocardial infarction during the outbreak of COVID-19 and outlines a practical algorithm for it.

A calorie-restricted diet with nuts favourably raises plasma high-density lipoprotein-cholesterol in overweight and obese patients with stable coronary heart disease: A randomised controlled trial.

BACKGROUND: Weight loss and consumption of nuts may both improve plasma lipids and lipoproteins. However, their effects in patients with coronary artery disease (CAD) who are under treatment with statins remain unclear. This study was conducted to determine plasma lipid and lipoprotein responses to a low-calorie (25% of energy deficit) nuts containing diet (NELCD) compared with a nut-free energy-restricted diet (NFLCD) in stable CAD patients who were overweight or obese (n = 67). METHODS: Plasma lipids and lipoproteins and ATP-binding cassette (ABC) A1 and ABCG1 mRNA expressions in peripheral blood mononuclear cells (PBMCs) isolated from patients were assessed at baseline and after 8 weeks. RESULTS: Plasma high-density lipoprotein (HDL) cholesterol and apoA1 increased significantly in the NELCD group at the end of Week 8 compared with those in NFLCD group (in NELCD group, mean change and 95% confidence interval (CI) were 1.17 [-1.31, 3.66] mg/dL, P = 0.012, and 2.55 [-2.10, 7.20] mg/dL, P = 0.011, for HDL cholesterol and apoA1, respectively). In both groups, the concentrations of total cholesterol, low-density lipoprotein cholesterol and triglyceride reduced significantly at Week 8 compared with those in baseline with no significant difference between the two groups. ABCA1 and ABCG1 mRNA expressions non-significantly decreased in both groups. CONCLUSION: This study indicates that inclusion of nuts as part of a calorie-restricted diet improves the concentrations of HDL cholesterol and apoA-1 in patients with stable, established CHD receiving statins.

The association between exposure to air pollutants including PM10, PM2.5, ozone, carbon monoxide, sulfur dioxide, and nitrogen dioxide concentration and the relative risk of developing STEMI: A case-crossover design.

BACKGROUND: Unfavorable associations between air pollution and myocardial infarction are broadly investigated in recent studies and some of them revealed considerable associations; however, controversies exists between these investigations with regard to culprit components of air pollution and significance of correlation between myocardial infarction risk and air pollution. METHODS: The association between exposure to PM10, PM2.5, ozone, carbon monoxide, sulfur dioxide, and nitrogen dioxide concentration of background air that residents of Tehran, the capital city of Iran, which is ranked as the most air polluted city of Iran and the relative risk of developing ST-elevation myocardial infarction (STEMI) were investigated by a case-crossover design. Our study included 208 patients admitted with a diagnosis of STEMI and undergone primary percutaneous intervention. Air pollutant concentration was averaged in 24-h windows preceding the time of onset of myocardial infarction for the case period. Besides, the mean level of each element of air pollution of the corresponding time in one week, two weeks and three weeks before onset of myocardial infarction, was averaged separately for each day as one control periods. Thus, 624 control periods were included in our investigation such that. Each patient is matched and compared with him/herself. RESULTS: The mean level of PM10 in case periods (61.47µg/m3) was significantly higher than its level in control periods (57.86µg/m3) (P-value = 0.019, 95% CI: 1.002-1.018, RR = 1.010). Also, the mean level of PM2.5 in case periods (95.40µg/m3) was significantly higher than that in control days (90.88µg/m3) (P-value = 0.044, 95% CI: 1.001-1.011, RR = 1.006). The level of other components including NO2, SO2, CO and O3 showed no significant differences between case and control periods. A 10µg/m3 increase in PM10 and PM2.5 would result in 10.10% and 10.06% increase in STEMI event, respectively. Furthermore, the results of sub-group analysis showed that older patients (equal or more than 60 year-old), diabetic patients, non-hypertensive ones and patients with more than one diseased vessel may be more vulnerable to the harmful effect of particular matters including PM10 and PM2.5 on development of STEMI. CONCLUSION: Air pollution is a worldwide pandemic with great potential to cause terrible events especially cardiovascular ones. PM2.5 and PM10 are amongst ambient air pollutant with a high risk of developing STEMI. Thus, more restrictive legislations should be applied to define a safe level of indoor and outdoor air pollutant production.

Reverse expression pattern of sirtuin-1 and histone deacetylase-9 in coronary artery disease.

BACKGROUND: SIRT1 and HDAC 9 genes are related to inflammation and may contribute to the pathogenesis of coronary artery disease (CAD). We aimed to evaluate the expression level, methylation profile and polymorphisms of these genes in CAD patients. METHODS: In this study, 50 CAD patients and 50 healthy individuals were recruited. The expression level change was evaluated using the TaqMan Real-Time PCR method. The methylation of genes promoter and genotyping of polymorphisms were evaluated by the HRM. RESULTS: The expression level of SIRT1 was reduced while the HDAC9 expression level showed a significant elevation (p < .001). The SIRT1 gene promoter was hypomethylated and the HDAC9 gene promoter was hypermethylated in CAD patients. Also, CG + GG genotype in SIRT1 and both genotypes in the HDAC9 gene were associated with expression change. CONCLUSIONS: SIRT1 and HDAC9 genes, expression changes can be suggested as a potential biomarker for CAD detection.

Associations between short-term exposure to fine particulate matter and acute myocardial infarction: A case-crossover study.

BACKGROUND: Previous studies evaluated the impact of particle matters (PM) on the risk of acute myocardial infarction (AMI) based on local registries. HYPOTHESIS: This study aimed to evaluate possible short term effect of air pollutants on occurrence of AMI based on a specific case report sheet that was designed for this purpose. METHODS: AMI was documented among 982 patients who referred to the emergency departments in Tehran, Iran, between July 2017 to March 2019. For each patient, case period was defined as 24 hour period preceding the time of emergency admission and referent periods were defined as the corresponding time in 1, 2, and 3 weeks before the admission. The associations of particulate matter with an aerodynamic diameter ≤2.5 µm (PM2 .5 ) and particulate matter with an aerodynamic diameter ≤10 µm (PM10 ) with AMI were analyzed using conditional logistic regression in a case-crossover design. RESULT: Increase in PM2.5 and PM10 was significantly associated with the occurrence of AMI with and without adjustment for the temperature and humidity. In the adjusted model each 10 µg/m3 increase of PM10 and PM2.5 in case periods was significantly associated with increase myocardial infarction events (95% CI = 1.041-1.099, OR = 1.069 and 95% CI = 1.073-1.196, and OR = 1.133, respectively). Subgroup analysis showed that increase in PM10 did not increase AMI events in diabetic subgroup, but in all other subgroups PM10 and PM2 .5 concentration showed positive associations with increased AMI events. CONCLUSION: Acute exposure to ambient air pollution was associated with increased risk of AMI irrespective of temperature and humidity.

Variation in the expression level of MALAT1, MIAT and XIST lncRNAs in coronary artery disease patients with and without type 2 diabetes mellitus.

Background: The MALAT1, MIAT, and XIST long noncoding RNAs (lncRNAs) participate in the pathogenesis of complex diseases and also serve as diagnostic markers. The study aimed to assess their expressions in CAD patients with or without T2DM against diabetic and non-diabetic controls.Methods: The expression levels of three lncRNAs in 50 CAD patients (with or without diabetes) and 50 non-CAD subjects (with or without diabetes) were evaluated by using the TaqMan Assay method.Results: MALAT1 and MIAT were upregulated in CAD patients (p Value= .0008 and .0078, respectively). The expression level of XIST was significantly elevated diabetic compared to non-diabetic CAD patients (p Value= .0003). MALAT1 gene had the highest diagnostic power for discrimination of CAD patients from controls (AUC= 0.682, p Value=.001).Conclusions: The current study supports the participation of lncRNAs in the pathogenesis of CAD and T2DM and highlights their potential as diagnostic biomarkers.

Opium consumption and coronary atherosclerosis in diabetic patients: a propensity score-matched study.

There is a traditional belief among Eastern people that opium may have ameliorating effects on cardiovascular risk factors, especially diabetes; thus, it is widely used among diabetic patients. We attempted to investigate the association of opium consumption with coronary artery disease (CAD) in diabetic patients. A cross-sectional study was conducted on diabetic patients undergoing coronary angiography in our center. Out of 1925 diabetic patients included in the study, 228 were opium users, and the remaining 1697 non-opium users were used as a pool of potential comparators. Propensity scores were used to match the 228 opium consumers with 228 matched comparators for age, sex, and smoking status. The Gensini score and extent score were respectively used to assess the angiographic severity and extent of CAD. The mean Gensini score (86.9 ± 62.7 vs. 59.6 ± 43.4, p < 0.0001) and extent score (7.1 ± 2.9 vs. 5.9 ± 2.9, p < 0.0001) were significantly higher in opium user diabetic patients than in non-opium users. After adjustment for potential confounders, a dose-response relationship was observed between dose of opium and the Gensini score ( ß = 0.27, p = 0.04). There were no significant differences between the routes of opium administration (inhalation vs. oral) regarding the severity and extent of CAD. In conclusion, exposure to opium in diabetic patients may be positively associated with the risk of CAD, and with the angiographically determined severity and extent of the disease. Furthermore, dosage of opium consumption may correlate with severity of CAD.

The No-reflow Phenomenon: Is it Predictable by Demographic factors and Routine Laboratory Data?

BACKGROUND: The coronary no-reflow phenomenon is an adverse complication of percutaneous coronary interventions (PCI) which significantly worsens the outcome and survival. In this study, we have evaluated the correlation of no-reflow phenomenon with demographic, biochemical and anatomical factors. METHODS: We included 306 patients (193 male) with acute ST-elevation myocardial infarction (STEMI) who undergone primary PCI in our center. Demographic factors, as well as biochemistry test results were obtained. Also, the Thrombolysis in Myocardial Infarction (TIMI) grade and TIMI frame count (TFC) was measured. The correlation of no-reflow phenomenon with demographic, biochemical and anatomical factors was analyzed. RESULTS: Patients with a mean age of 56.41 ± 11.8 years were divided into two groups depending on the TIMI score (Group 1 or Normal flow and Group 2 or No-reflow). Symptom-to-procedure time, door-to-procedure time, serum creatinine level, hs-CRP level, and Neutrophil to Lymphocyte Ratio (NLR) were significantly higher among group 2. TFC had negative significant correlation with male gender, and positive significant correlation with age, diabetes mellitus, hs-CRP level, WBC count, and NLR. Age of more than 62.5 years and serum creatinine level of more than 0.89 mg/dL can optimally predict the no reflow phenomena. CONCLUSIONS: According to our results, it seems that female gender, older ages, DM, multi-vessel involvement, delayed reperfusion, and increased NLR can predict the risk of no-reflow after primary PCI in the setting of Acute Myocardial Infarction.

Value of Transverse Groove on the Earlobe and Hair Growth on the Ear to Predict the Risk for Coronary Artery Disease and Its Severity among Iranian Population, in Tehran City.

BACKGROUND: The use of phenotypic parameters along with other noninvasive diagnostic modality can lead to early diagnosis of coronary artery disease (CAD) and prevent its life-threatening outcome. Recently, the application of head and face components for assessing the risk for CAD much attention has been paid. The present study aimed to assess the relationship between ear characteristics (transverse groove on the earlobe and hair growth on the ear) and the risk for CAD and its severity among Iranian patients. MATERIALS AND METHODS: In this cross-sectional study, the study population consisted of 105 consecutive patients with suspected CAD undergoing coronary angiography. The severity of CAD was determined by the number of disease vessels as well as the presence of left main lesions assessed by coronary angiography. All patients were examined to evaluate the appearance of ear regarding the presence of transverse groove on the earlobe and hair growth on the ear. RESULTS: Comparing cardiovascular parameters across the groups with and without transverse groove on the earlobe showed a higher rate of CAD as well as the higher number of involved coronary arteries than in the groups without transverse groove on the earlobe. Similarly, the presence of CAD and its higher severity were more revealed in patients with hair growth on the ear as compared to the group without this phenotype. According to multivariable logistic regression analysis and with the presence of baseline parameters, the presence of transverse groove on the earlobe and hair growth on the ear increased the risk for CAD by 2.4 and 4.4 fold, respectively. CONCLUSION: Along with classic cardiovascular risk factors, the role of growing hair on the ear and transverse groove on the ear to predict high risk for CAD should be considered.

The Potential Effect of Intravenous Calcitriol on the Ischemia-Reperfusion Process and Inflammatory Biomarkers in Patients Following Percutaneous Coronary Intervention (PCI).

This study aimed to investigate the efficacy of calcitriol on Ischemia-reperfusion Injury (IRI) and inflammatory biomarkers in patients with non-ST-segment elevation acute coronary syndromes (NSTEACS) undergoing elective Percutaneous Coronary Intervention (PCI). A total of 72 patients with NSTEACS were randomly divided into two groups: (1) the calcitriol-treated group, treated with three mcg intravenous calcitriol administered before PCI (n = 36) and (2) the control-treated group (n = 36) The serum high-sensitivity C-reactive protein (hs-CRP), high-sensitivity interleukin-6 (hs-IL-6), creatinine kinase (CK)-MB and cardiac troponin I (cTnI) levels were measured before PCI and 24 h after PCI in both groups. The patients were followed up for the detection of the prevalence of major adverse cardiac events (MACE) in 180 days after PCI in both groups. Compared to pre-PCI, the serum hs-CRP, hs-IL-6, CK-MB, and cTnI levels were increased at 24 h after PCI (all p < 0.05) in both groups. However, change in the levels of hs-CRP and hs-IL-6 were significant (p = 0.04 and p = 0.02, respectively). Changes in the levels of CK-MB and cTnI were non-significant (p = 0.15 and p = 0.39, respectively). No MACE (death, Q wave MI, target vessel revascularization, ischemic stroke) was detected in any patient in any group during a 3-month follow-up. Administration of calcitriol in patients with non-ST-segment elevation acute coronary syndromes undergoing elective PCI can attenuate the increase in serum inflammatory biomarkers in the serum (hs-CRP and hs-IL-6) and thus decrease the inflammatory reaction caused by PCI.

The role of FFR in clinical decision making in patients with moderate coronary lesions: a pilot study.

BACKGROUND AND AIM: Applying fractional flow reserve (FFR) recently helped to assess borderline coronary defects and also facilitates assessment of these lesions. The present study aimed to assess cost-effectiveness of FFR in detection of these borderline lesions. METHODS: This cross-sectional study was conducted on140 consecutive patients with 219 diseased arteries who underwent coronary angiography and suffered intermediate coronary lesions. RESULTS: Of 18 patients who candidate for CABG before FFR, only one patient underwent CABG after determining FFR (P-value<0.05), while 15 patients were scheduled for PCI and 2 patients for medical treatment. Of 122 patients who candidate for PCI, 59 were programmed to underwent PCI after FFR determination(P-value<0.05), while the strategy in 63 patients (47 with one-vessel disease, 15 with two vessel diseases, and 1 with three vessel diseases) was modified to medical treatment. Considering strategy modifying from PCI to medical treatment, 101 stents were saved (P-value<0.05). Also, in change of strategy from CABG to PCI, spending has decreased as much as 77.3% (P-value<0.05). Furthermore, the change of treatment approach from PCI on much number of coronary vessels to PCI on less number of coronary lesions led to saving of 52.2% of costs(P-value<0.05). CONCLUSIONS: In patients with an intermediate coronary lesion, measuring FFR to guide the decision to determine treatment strategy may lead to significant cost savings.

Rest 2D speckle tracking echocardiography may be a sensitive but nonspecific test for detection of significant coronary artery disease.

AIMS: To detect the significance of coronary artery disease in the patients, who are suspected, was assumed to be one of the advantages of 2D STE, as a novel non-invasive imaging modality with acceptable accuracy. METHODS: In this study, 216 patients who were suspected to have coronary artery disease and candidate for coronary angiography, underwent rest two-dimensional speckle tracking echocardiography (2D STE) and negative global systolic longitudinal strain was evaluated. RESULTS: Negative global systolic left ventricular longitudinal strain under 18% in rest 2D-STE was significantly prevalent in patients with significant CAD in coronary angiography (P value<0.0001).Our results revealed sensitivity of 91.1%, specificity of 63.0%, positive predictive value of 80.4%, negative predictive value of 81.0% and accuracy of 80.5% for rest 2D-STE in detection of significant CAD. CONCLUSION: Here in we showed that rest Two-dimensional speckle tracking echocardiography could be a sensitive but nonspecific imaging modality to determine significant coronary artery disease. Future studies with large size will reveal more detailed findings.

Evaluation of pentraxin-3 level and its related factors in patients undergoing primary percutaneous coronary intervention.

BACKGROUND: Inflammation has an important role in the development and progression of atherosclerosis, and acute phase proteins such as pentraxin-3 (PTX3) can be deployed in determining the prognosis of coronary artery disease (CAD). So the purpose of this paper was to evaluate the PTX3 level and its related factors in patients undergoing primary percutaneous coronary intervention (PCI). METHODS: In this cross-sectional study, the PTX3 levels were determined for 100 patients with ST-elevation myocardial infarction referred to the Modarres Hospital, Tehran, Iran. Checklist included demographic data [age, gender, history of myocardial infarction (MI)] and characteristics of heart disease (type of MI, culprit, and pre-dilation). PTX3 was measured for all patients before PCI. RESULTS: In this study, the mean age of the participants was 58.7 (11.4). Global registry of acute coronary events (GRACE) score was higher in the group with abnormal PTX3 levels (P = 0.008). The number of the involved vessels (P = 0.005), MI type (P = 0.05), and the need for PCI all had a significant relation with abnormal PTX3 levels. The increased levels of PTX3 received higher Killip class, lower ejection fraction, and higher GRACE score. The group with abnormal PTX3 had a significant difference in platelet counts (P = 0.018) in comparison with the group with normal level of PTX3. CONCLUSION: Currently, the biomarkers are highly important in the field of cardiovascular diseases. The diagnostic and prognostic importance of PTX3 as a new marker has been underscored in recent studies. Differentiating between high-risk patients with acute cardiac infarction and low-risk ones through their clinical signs is difficult.

Successful Treatment of a Left Main Thrombus by Intracoronary Eptifibatide Infusion in a 36-Year-Old Patient.

The acute coronary syndrome due to the left main coronary artery (LMCA) thrombosis is a clinically rare and catastrophic event. We describe a young man (smoker, alcoholic, and drug abuser) with a history of recent surgery and typical chest pain who had non-occlusive LMCA thrombosis in coronary angiography. The thrombosis was successfully treated with two 180 µ/kg intracoronary boluses of eptifibatide, which was continued through an intravenous infusion at 2 µ/kg/min for 48 hours postprocedurally. Control angiography, performed 3 days later, revealed that the LMCA was free of thrombosis. The patient had no complaints, including chest pain, and remained completely asymptomatic during the next 30 days' follow-up.

Serum Troponin I Level for Diagnosis of Acute Coronary Syndrome in Patients with Chronic Kidney Disease.

INTRODUCTION: Myocardial infarction is a common cause of mortality in patients with chronic kidney disease (CKD). Since troponins I and T levels rise in CKD patients without any myocardial cause, diagnostic value of cardiac troponins is not high in these patients. This study aimed to evaluate the value of troponin I and other cardiac biomarkers to differentiate acute coronary syndrome in CKD patients. MATERIALS AND METHODS: In this cross-sectional study, patients with stage 3 to 5 of CKD with typical chest pain were enrolled. Troponins I and T and other biomarkers were measured, and angiography was carried out in these patients. Cardiac biomarkers and other variables were evaluated in patients and compared with angiography results. RESULTS: Ninety CKD patients with a mean age of 61.67 ± 15.87 years were enrolled. Angiography results were normal in 48.9% of the patients, while it showed single-vessel disease in 14.5%, two-vessel disease in 23.3%, and three-vessel disease in 13.3%. Serum creatinine level, glomerular filtration rate, troponin I level, and creatine kinase level were not significantly different in patients with normal and abnormal angiography findings. The serum troponin I, creatine kinase, and creatine kinase-myocardial bound levels had no significant diagnostic values to differentiate abnormal angiography in CKD patients. CONCLUSIONS: Serum levels of cardiac troponin I and creatine kinase-myocardial bound were not suitable to diagnose ACS in CKD patients (stages 3 to 5); therefore, we suggest using other diagnostic attempts in similar conditions. More evaluation is needed to confirm these findings.

Stent underexpansion in angiographic guided percutaneous coronary intervention, despite adjunctive balloon post-dilatation, in drug eluting stent era.

BACKGROUND: Stent underexpansion is the most powerful predictor of long-term stent patency and clinical outcome. The purpose of this study was to evaluate the incidence and predictors of stent underexpansion despite adjunctive post-dilatation with non-compliant balloon. METHODS: After elective coronary stent implantation and adjunctive post-dilatation with non-compliant balloon and optimal angiographic result confirmed by the operator, intravascular ultrasound (IVUS) was performed for all the treated lesions. If the treated lesions fulfilled the IVUS criteria, they are considered as the optimal stent group; if not, they are considered as the suboptimal group. RESULTS: From 50 patients enrolled in this study 39 (78%) had optimal stent deployment and 11 (22%) had suboptimal stent deployment. In the suboptimal group 7 (14%) had underexpansion, 2 (4%) malposition, and 2 (4%) had asymmetry. There were no stent edge dissections detected by IVUS. We did not find any correlation between lesion calcification, ostial lesions, stent length, and stent underexpansion. Stent diameter ≤ 2.75 mm had a strong correlation with stent underexpansion. CONCLUSION: Despite adjunctive post-dilatation with noncompliant balloon, using a relatively small stent diameter was a strong predictor for underexpansion. IVUS guided percutaneous coronary intervention (PCI) may be considered for drug eluting stent (DES) implantation in relatively small vessels.

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.