The Delayed Diagnosis of a Submassive Pulmonary Embolism Following Influenza A Infection Treated With Half-Dose Tenecteplase: A Case Report.

The coronavirus 2019 (COVID-19) pandemic has brought renewed attention to thrombotic complications arising from respiratory viral infections, driven by inflammatory responses and activation of the coagulation cascade. While influenza typically resolves on its own, information about its thromboembolic risks remains limited. The persistence of symptoms and the similarity between influenza symptoms and those of pulmonary embolism (PE) often lead to diagnostic delays, which can significantly impact patient outcomes. We discuss a case of a 62-year-old woman with a history of hypertension and hyperlipidemia who presented with dyspnea, syncope, and persistent symptoms following influenza A infection. Despite initial treatment with Tamiflu and subsequent antibiotics for presumed pneumonia, her condition worsened, leading to syncope and admission to the hospital. A diagnostic workup revealed saddle pulmonary emboli with right ventricular strain. She was treated with a half-dose of tenecteplase, resulting in significant clinical improvement and a notable reduction in thrombus burden on follow-up imaging. The thromboembolic complications of influenza A are not extensively documented compared to COVID-19, yet they can present with severe outcomes. Submassive PE, characterized by hemodynamic stability with signs of right ventricular strain, poses treatment challenges. While full-dose thrombolytics are generally avoided in intermediate-risk PE due to bleeding risks, half-dose thrombolytics such as tenecteplase can offer a safer alternative. Though not FDA-approved specifically for PE, tenecteplase has shown efficacy and was effectively used in this case. Half-dose thrombolytics, including tenecteplase, may be a viable treatment option for certain cases of PE, offering a balance between efficacy and safety. This case highlights the importance of considering PE in patients with persistent respiratory symptoms post-influenza and demonstrates the potential of tenecteplase in managing submassive PE.

A Survey of Medical Residents' Knowledge, Attitude, and Practice about Drug-Drug Interactions, Shiraz, Iran.

Rationale, aims and objectives: Medical residents are among the most important and influential members of the medical team and the level of their knowledge regarding potential drug-drug interactions (DDIs) is a good predictor of the ability to prevent the occurrence of DDIs, as well as safe and rational prescribing in inpatient settings. This survey was designed to evaluate internal medicine and cardiology residents' knowledge and opinion toward DDIs and to determine different sources of DDI information used by this population. Method: This cross-sectional knowledge attitude practice (KAP) questionnaire study was conducted in Shiraz, Iran. A 25-question questionnaire was designed and completed by 86 internal medicine and cardiology residents. The questions were related to the participants' demographic information, their practice characteristics, the information sources used by the participants, the residents' opinion regarding DDIs, and their knowledge regarding the interaction between 8 drug pairs. Results: The results showed that when the participants wanted to learn more about DDIs, most of them used software on mobile or tablet (59.3%). Nearly three-fourths of the participants (73.82%) reported that when a patient was about to be exposed to a potential DDI, they were informed by software on mobile or tablet that the interaction may be present. On average, residents answered 44.03% ± 23.79 of drug pair questions correctly.Conclusion: Our results show insufficient practice skills, as well as relatively poor knowledge concerning the participants' answers to questions. It seems that further practical training and education are required to enable prescribers to prevent potential DDIs.

Prevention of adhesive capsulitis following pacemaker implantation: A randomized controlled study.

INTRODUCTION: Gradual painful loss of active and passive range of motion in shoulder joint was introduced as adhesive capsulitis (AC). Disabilities in patients with AC are absenteeism from work, loss to leisure time, and recurrent seeking to health care services. The aim of this study was to evaluate the incidence of AC following pacemaker implementation. The effect of physical therapy and exercise education was also evaluated to prevent AC following pacemaker implementation. METHODS: This study is a randomized clinical controlled trial. It was conducted on 62 pacemaker candidates. Patients with no shoulder pain and without any motion limits were enrolled in the study consecutively. The patients randomly were divided into two groups after pacemaker implementation. One group was treated with physical therapy (group A, n = 28) and the other group did not (group B, n = 34). The incidence of AC was assessed in both groups after 4 months. RESULTS: A total of 62 patients were enrolled in the study. The mean age was 63.2 ± 12.1 years in the group A and 67.1 ± 17.6 years in the group B. Age was not significantly different between groups. A total of 11 patients (17.7%) had AC 16 weeks after the initial visit (two patients in group A and nine patients in group B; P = .004). CONCLUSIONS: Incidence of AC is 17.7% following device implantation. Exercise education and physical therapy significantly reduces AC incidence following pacemaker implantation.

The effects of coenzyme Q10 supplementation on biomarkers of inflammation and oxidative stress in among coronary artery disease: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: Systemic inflammation and oxidative stress significantly contribute in developing coronary artery disease (CAD). This systematic review and meta-analysis was aimed to determine the effects of coenzyme Q10 (CoQ10) supplementation on biomarkers of inflammation and oxidative stress among patients with CAD. METHODS: The electronic databases including MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane Library databases were systematically searched until Oct 2018. The quality assessment and heterogeneity of the selected randomized clinical Trials (RCTs) were examined using the Cochrane Collaboration risk of bias tool, and Q and I2 tests, respectively. Given the presence of heterogeneity, random-effects model or fixed-effect model were used to pool standardized mean differences (SMDs) as summary effect sizes. RESULTS: A total of 13 clinical RCTs of 912 potential citations were found to be eligible for the current meta-analysis. The pooled findings for biomarkers of inflammation and oxidative stress demonstrated that CoQ10 supplementation significantly increased superoxide dismutase (SOD) (SMD 2.63; 95% CI, 1.17, 4.09, P < 0.001; I2 = 94.5%) and catalase (CAT) levels (SMD 1.00; 95% CI, 0.57, 1.43, P < 0.001; I2 = 24.5%), and significantly reduced malondialdehyde (MDA) (SMD - 4.29; 95% CI - 6.72, - 1.86, P = 0.001; I2 = 97.6%) and diene levels (SMD - 2.40; 95% CI - 3.11, - 1.68, P < 0.001; I2 = 72.6%). We did not observe any significant effect of CoQ10 supplementation on C-reactive protein (CRP) (SMD - 0.62; 95% CI - 1.31, 0.08, P = 0.08; I2 = 87.9%), tumor necrosis factor alpha (TNF-α) (SMD 0.22; 95% CI - 1.07, 1.51, P = 0.73; I2 = 89.7%), interleukin-6 (IL-6) (SMD - 1.63; 95% CI - 3.43, 0.17, P = 0.07; I2 = 95.2%), and glutathione peroxidase (GPx) levels (SMD 0.14; 95% CI - 0.77, 1.04, P = 0.76; I2 = 78.7%). CONCLUSIONS: Overall, this meta-analysis demonstrated CoQ10 supplementation increased SOD and CAT, and decreased MDA and diene levels, but did not affect CRP, TNF-α, IL-6, and GPx levels among patients with CAD.

The effects of coenzyme Q10 supplementation on lipid profiles among patients with coronary artery disease: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Chronic inflammation and increased oxidative stress significantly contribute in developing coronary artery disease (CAD). Hence, antioxidant supplementation might be an appropriate approach to decrease the incidence of CAD. This systematic review and meta-analysis was aimed to determine the effects of coenzyme Q10 (CoQ10) supplementation on lipid profile, as one of the major triggers for CAD, among patients diagnosed with coronary artery disease. METHODS: EMBASE, Scopus, PubMed, Cochrane Library, and Web of Science were searched for studies prior to May 20th, 2018. Cochrane Collaboration risk of bias tool was applied to assess the methodological quality of included trials. I-square and Q-tests were used to measure the existing heterogeneity across included studies. Considering heterogeneity among studies, fixed- or random-effect models were applied to pool standardized mean differences (SMD) as overall effect size. RESULTS: A total of eight trials (267 participants in the intervention group and 259 in placebo group) were included in the current meta-analysis. The findings showed that taking CoQ10 by patients with CAD significantly decreased total-cholesterol (SMD -1.07; 95% CI, - 1.94, - 0.21, P = 0.01) and increased HDL-cholesterol levels (SMD 1.30; 95% CI, 0.20, 2.41, P = 0.02). We found no significant effects of CoQ10 supplementation on LDL-cholesterol (SMD -0.37; 95% CI, - 0.87, 0.13, P = 0.14), lipoprotein (a) [Lp(a)] levels (SMD -1.12; 95% CI, - 2.84, 0.61, P = 0.20) and triglycerides levels (SMD 0.01; 95% CI, - 0.22, 0.24, P = 0.94). CONCLUSIONS: This meta-analysis demonstrated the promising effects of CoQ10 supplementation on lowering lipid levels among patients with CAD, though it did not affect triglycerides, LDL-cholesterol and Lp(a) levels.

Atrioventricular nodal echoes over a wide echo window as a therapeutic end point for the catheter-guided radiofrequency ablation of atrioventricular nodal reentrant tachycardia: a prospective study.

Aims: In previous retrospective studies, it was shown that the presence of residual single atrioventricular node (AVN) echoes with an echo zone longer than 30 ms may increase the rate of recurrence after radiofrequency ablation (RFA) of slow pathway in patients with AVN reentrant tachycardia (AVNRT). Based on that, some centres perform additional RFA in these patients. However, this opinion has never been tested prospectively and many centres do not perform re-ablation in these patients. The purpose of this study was to test whether persistence of a single AVN echo over a wide echo zone is a valid end point for RFA. Methods and results: In this prospective study, 576 patients who had a non-inducible arrhythmia post-RFA of AVNRT were divided into those with a remnant echo over a wide echo zone (case group) and those reaching classical end points (control group). The primary end point of the study was recurrence and patients were followed for 34.5 ± 18.8 months. In the control group (n = 510), 14 patients (2.7%) had a recurrence while no recurrence was seen in the case group (n = 66) (final cure rate, 97.3 vs. 100%; difference, 2.7%; upper bound of the 98% CI, 0.0488; P < 0.0001 for non-inferiority). Two complete heart blocks (0.4%) happened in the control group and none in the case group (P = 0.784). Conclusion: Non-inducibility in the presence of a wide echo window is non-inferior to non-inducibility in the presence of narrow echo window or no AVN echoes. In general, the presence of a single echo beat is not an indication for further ablation and this applies for both narrow and wide windows.

Effect of Cardiac Resynchronisation Therapy on Electrical Remodelling.

BACKGROUND: Cardiac resynchronisation therapy (CRT) is an accepted device therapy in patients with low ejection fraction. Beneficial effects of CRT result from mechanical remodelling. Some controversial reports suggest that CRT may also induce electrical remodelling with intrinsic QRS narrowing but still the effect of CRT on electrical remodelling is an issue for debate. The aim of our study was to evaluate the effects of CRT on intrinsic QRS duration. For clarity, our analysis was performed by the signal averaged electrocardiogram (SAECG) which is a high resolution electrocardiographic signal suitable for accurate measurement of QRS duration. Signal averaged electrocardiogram provides a better value of QRS duration compared to 12-lead ECG by the ability to detect ventricular late potentials. METHODS: A total of 48 consecutive patients with severe systolic dysfunction and typical left bundle branch block (LBBB) were enrolled in the study prospectively. Patients were scheduled for CRT-D implantation according to the current guidelines. Intrinsic QRS duration was accurately measured by SAECG before and at least 14 months after CRT implantation. RESULTS: The mean intrinsic QRS duration remained unchanged during follow-up (from 149.9±13.8ms to 149.6±18.4ms; P= 0.3). Among 32 CRT responder patients, the mean intrinsic QRS duration remained unchanged during follow-up. Also, the mean intrinsic QRS duration showed no significant changes in 16 CRT non-responders. CONCLUSION: Structural remodelling induced by CRT does not necessarily translate into decrease of intrinsic ventricular activation. Despite significant left ventricular recovery, electrical characteristics of the left ventricular conduction system cannot generally be expected to recuperate.

Evaluation of the effect of radiofrequency catheter ablation on autonomic function in patients with atrioventricular nodal reentrant tachycardia by head-up tilt table test.

BACKGROUND: One of the recommended treatments for atrioventricular nodal reentrant tachycardia (AVNRT), is radiofrequency catheter ablation (RFCA). However, RFCA may affect the autonomic system. This study aims to evaluate the effect of RFCA on autonomic system in patients with PSVT by head-up tilt table (HUTT) test. MATERIALS AND METHODS: In a before-after study, 22 patients with PSVT were enrolled. Data were collected with a data collection form that included two parts. Electrocardiogram (ECG), echocardiogram, 24-h Holter monitoring, HUTT test, heart rate variability (HRV) indexes, and symptoms of all patients were recorded 24 h before and 1 month after the ablation. Wilcoxon, McNemar, Mann-Whitney U, and Chi-square tests were used to analyze the data. RESULTS: Of the total 22 patients, 31.8% were male and 68.2% were female. There were significant differences in heart palpitation (P < 0.0001) and non-specific symptoms (P = 0.031) and no significant difference in head-up tilt test results and HRV indices before and after RFCA. The results showed that there were no significant differences in specific and non-specific symptoms in patients with AVNRT with positive and negative HUTT before and after RFCA. CONCLUSIONS: The observed difference in heart palpitation and non-specific symptoms emphasized the role of AVNRT in causing these symptoms. Autonomic dysfunction is more probably an accompanying condition of AVNRT than causing symptoms. We could not find any significance in the results of HUTT after RFCA. HUTT cannot determine or predict the symptoms after RFCA.

Implanting CRT via Endo-Cardiac Route When Tricuspid Valve is Metallic.

Prosthetic tricuspid valve is an obstacle to implant cardiac devise. Cardiac Resynchronization therapy is one of the most popular therapies for heart failure patients these days. We present this case of prosthetic tricuspid valve and left ventricular dysfunction which we overcome the problem by implanting two leads to coronary sinus branches. Patient improved in few months of follow up.

Persistent isolated right atrial standstill associated with left atrial tachycardia.

INTRODUCTION: Atrial standstill is a rare condition, characterized by absence of atrial electrical and mechanical activity evident in surface electrocardiography echocardiography, or fluoroscopy, which is associated with unresponsiveness of atria to maximal output electrical stimulation. This condition can be present with thromboembolic complication, low cardiac output, and sometimes palpitation. CASE PRESENTATION: Here we presented a woman with right atrial stand still and left atrial tachycardia. It was confirmed by electrocardiogram, echocardiography, and intracardiac electrogram in basal state and during maximal output electrical stimulation. We treated her by implanting pacemaker to control bradycardia, oral calcium channel blocker to control palpitation episodes, and anticoagulation. CONCLUSIONS: Atrial standstill can be present partially that can be localized in one atrium and is associated with tachycardia in the other atrium.

Effect of inpatient cardiac rehabilitation on QT dispersion in patients with acute myocardial infarction.

QT dispersion is an indicator of lack of ventricular repolarization homogeneity and an independent predictor for ventricular arrhythmia and sudden cardiac death. In this study, we evaluated the effect of inpatient cardiac rehabilitation on QT dispersion in patients admitted to Afshar hospital CCU with diagnosis of acute myocardial infarction (AMI), including ST elevation or non-ST elevation MI. Sixty patients with diagnosis of AMI were randomly divided into two 30-subject groups. The subjects in the first group were undergone inpatient cardiac rehabilitation, and the subjects in the control group received only conventional treatments. QT interval dispersion was measured in two occasions: once in the first day of admission and once before discharge from hospital. In this study there was a significant reduction in QT dispersion in patients undergoing inpatient cardiac rehabilitation (48.4 vs. 42.4 ms, P<0.001), but in the control group, QT dispersion was not significantly reduced (49.2 vs. 46.2 ms, P>0.05). The reduction was not significantly different regarding gender. The effectiveness of the rehabilitation on the reduction of QT dispersion was not affected by such variables as age, gender, hypertension, positive family history, hyperlipidemia, type of AMI (with ST-elevation or non-ST-elevation) and left ventricular ejection fraction. Diabetes caused a resistance to the beneficial effects of inpatient cardiac rehabilitation, so as non-diabetic patients showed more reduction in QT dispersion in response to inpatient cardiac rehabilitation comparing non-diabetic patients and the difference was statistically significant.

Prediction of response to cardiac resynchronization therapy using simple electrocardiographic and echocardiographic tools.

AIMS: To predict response to cardiac resynchronization therapy (CRT) in patients with heart failure (HF) and intraventricular conduction delay. METHODS AND RESULTS: The study population consisted of 82 consecutive HF patients with standard CRT indications. Patients were classified as responders, if they were alive without cardiac decompensation and experienced >or=15% decrease in left ventricular end-systolic volume. Sixty-eight percent of the enrolled patients responded to CRT. When compared with non-responders, responders had a wider baseline QRS width (P = 0.001), more marked QRS shortening (DeltaQRS) immediately after CRT (P = 0.001), and a better improvement in aortic velocity time integral (VTI) 24 h after CRT (P = 0.02). Moreover, there was a trend towards a greater baseline intraventricular dyssynchrony in the responder group (P = 0.07). By multivariable logistic regression, the baseline QRS width (OR: 0.95, 95% CI: 0.90-0.97, P = 0.001), DeltaQRS (OR: 1.038, 95% CI: 1.012-1.064, P = 0.003), and acute aortic VTI (OR: 0.81, 95% CI: 0.68-0.96, P = 0.017) emerged as independent predictors of response to CRT. Receiver operating characteristic curve analysis identified a QRS width >145 ms, DeltaQRS >20 ms, and aortic VTI >14 cm to predict responders. CONCLUSION: A positive response to CRT was observed in 68% of the patients. Cardiac resynchronization therapy response is predictable using simple electrocardiographic and echocardiographic data.

Effect of right ventricular lead location on response to cardiac resynchronization therapy in patients with end-stage heart failure.

AIMS: It is currently recommended to implant the left ventricular (LV) pacing lead at the lateral wall. However, the optimal right ventricular (RV) pacing lead location for cardiac resynchronization therapy (CRT) remains controversial. We sought to investigate whether optimizing the site for placement of the RV lead could further improve the long-term response to CRT in patients with advanced heart failure. METHODS AND RESULTS: Between October 2006 and December 2007, a total of 73 consecutive patients with standard indication for CRT were enrolled. The enrolled patients were divided into two groups based on the RV lead location. There were 50 patients in RV apex (RVA) group and 23 patients in RV high septum (RVHS). The primary study endpoint was a decrease in LV end-systolic volume (LVESV) by >15% at 6-month follow-up. The secondary endpoints were improvement in New York Heart Association (NYHA) class by >or=1 point and decrease in brain-type natriuretic peptide (BNP) levels by >50% after CRT. At 6-month follow-up, improvement in NYHA class by >or=1 point (RVA: 72% vs. RVHS: 74%, P = 0.76), decrease in LVESV by >or=15% (RVA: 65% vs. RVHS: 64%, P = 0.76), and decrease in BNP level by >50% (RVA: 70% vs. RVHS: 69%, P = 0.88) were observed in similar proportion of the two groups. When we separately assessed the significance of RV pacing site in three LV stimulation sites, there were no significant differences in terms of clinical improvement (62 vs. 64%, P = 0.74) and decrease in LVESV by >15% (63 vs. 62%, P = 0.78) between RVA and RVHS pacing when the LV stimulation site was lateral cardiac vein. In anterolateral vein pacing site, the RVA stimulation was associated with higher clinical (88 vs. 47%, P = 0.05), echocardiographic (75 vs. 32%, P = 0.02), and neurohormonal responses (80 vs. 50%, P = 0.04) compared with that in RVHS site. When LV was paced from posterolateral vein, RVHS pacing was superior to RVA in terms of the clinical improvement (85 vs. 35%, P = 0.01), echocardiographic response (72 vs. 30%, P = 0.01), and decrease in BNP levels (75 vs. 50%, P = 0.04). CONCLUSION: The present study did not show any difference between RVA and RVHS pacing sites in terms of overall improvement in clinical outcome and LV reverse remodelling following CRT. However, effect of RV lead location on CRT response varies depending on LV stimulation site.

Predictors and frequency of conduction disturbances after open-heart surgery.

INTRODUCTION: The risk of developing conduction disturbances after coronary bypass grafting (CABG) or valvular surgery has been well established in previous studies, leading to permanent pacemaker implantation in about 2% to 3% of patients, and in 10% of patients undergoing repeat cardiac surgery. We sought to determine the incidence, features and predictors of conduction disorders in the immediate post-operative period of patients subjected to open-heart surgery, and the need for permanent pacemaker implantation. MATERIAL AND METHOD: We prospectively studied 374 consecutive patients who underwent open-heart surgery in our institution: coronary artery bypass (CABG) (n=128), Mitral valve replacement(MVR)(n=18), aortic valve replacement(AVR) (n=21), MVR and AVR(n=56), repair of ventricular septal defect (VSD) (n=51), repair of tetralogy of Fallot (TOF) (n=57),CABG and valvular surgery (n=6), others (n=37). RESULTS: Among 374 patients included in our study (mean age 34.46+/-25.68; 146 males), 192 developed new conduction disorders: symptomatic sinus bradycardia in 8%, atrial fibrillation with slow ventricular response (AF) in 4.5%, first-degree atrioventricular block (AVB)in 6.4%, second-degree AVB in 0.3%, third-degree AVB in 7%, new right bundle branch block (RBBB) in 33%, and new left bundle branch block (LBBB) in 2.1%. In 5.6% patients, a permanent pacemaker was implanted, 47.6% of them underwent valvular surgery. In 44.1% of patients the conduction defects occurred in the first 48 hr. after surgery. In CABG group, 29.7% of patients developed new conduction disturbances; the most common of them was symptomatic sinus bradycardia. After valvular surgery 44.2% of patients developed conduction disturbances, of those the most common was atrial fibrillation with slow ventricular response . After VSD and TOF repair, the most common conduction disturbance was new RBBB. Perioperative myocardial infarction (MI) occurred in 1.9% of patients. The occurrence conduction disturbance was compared with patient age, sex, occurrence of perioperative MI, ejection fraction (EF), postoperative use of ss-adernergic receptor blocking agents and digitalis and type of cardiac surgery. By regression analysis there was a correlation between type of surgery and new conduction defects, being significant for CABG and TOF repair. Only the occurrence of perioperative MI was related to PPM implantation. CONCLUSION: Irreversible AVB requiring a PPM is an uncommon complication after open-heart surgery. Peri-operative MI is a risk factor.

Can successful radiofrequency ablation of atrioventricular nodal reentrant tachycardia be predicted by pattern of junctional ectopy?

BACKGROUND: Emergence of junctional rhythm (JR) during radiofrequency (RF) current delivery directed at the periatrioventricular nodal region has been shown to be a marker of success in atrioventricular nodal reentrant tachycardia (AVNRT). Whereas the characteristics of JR during RF ablation of slow pathway have already been studied, the electrophysiologic features of different patterns of JR are yet to be evaluated. The aim of this study was to investigate in detail the characteristics of the JR that develops during the RF ablation of the slow pathway. MATERIALS AND RESULTS: The study population consisted of 95 patients: 56 women and 33 men (mean age, 47.2 +/- 16.3 years) who underwent slow pathway ablation because of AVNRT. A combined anatomical and electrogram mapping approach was used, and AVNRT was successfully eliminated in all patients. This study identified 7 patterns for JR during the RF ablation of slow pathway: junction-junction-junction, sinus-junction-sinus, intermittent burst, sparse, no junction, sinus-junction-junction, and sinus-junction-block . The characteristics of JR, such as mean cycle length and total number, were gathered. The incidence of JR was significantly higher during effective applications of RF energy than during ineffective applications (P = .001). The mean number of junctional ectopy was 19.6 +/- 19. The total number of junctional ectopy was significantly higher during effective applications of RF energy than during ineffective applications (24.6 +/- 18.8 vs 8.4 +/- 13.2; P < .001). We found a significant difference between the effective and ineffective applications of RF energy in the mean cycle length of the junctional ectopy (464.6 +/- 167.5 vs 263.4 +/- 250.2; P < .01). The patterns of JR were compared between effective and ineffective applications. We managed to show a significant correlation between patterns of JR and successful ablation (P = .01). Logistic regression analysis revealed that the presence of sinus-junction-sinus, sinus-junction-junction, and sinus-junction-block patterns of JR was a predictor of a successful RF ablation (confidence interval [CI], 1.67-15.92 [P < .004]; CI, 1.02-85.62 [P = .048]; and CI, 1.06-32.02 [P = .042], respectively). CONCLUSION: This study confirms that JR is often present during successful slow pathway ablation. The pattern of JR is useful as indicator of success.