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.

The Potential Impact of Statins in the Treatment of Patients with COVID-19 Infection.

INTRODUCTION: Statins are cholesterol-lowering drugs that also have anti-inflammatory/ immunomodulatory properties, and have been suggested as an adjunct therapy for COVID-19. METHODS: To investigate the clinical impact of statins as a potential therapeutic approach in the treatment of cases infected with COVID-19, a systematic search was performed using PubMed and Google Scholar databases. To extend the search results, a set of keywords were used as follows: ("corona virus" OR "Covid-19" OR "SARS-Cov-2" OR "Severe Acute Respiratory Syndrome Coronavirus 2" OR coronavirus) AND (Statins), alongside a manual search in Google Scholar search engine. RESULTS: It has also been suggested that statins could influence the entry of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) into cells by altering the expression of the angiotensin-converting enzyme 2 (ACE2) and CD143 receptors. Statins may be beneficial for COVID-19 patients according to its pleiotropic effects, although, from the clinical aspect, these pleiotropic effects of statins may not be as strong as in preclinical phase on COVID-19. A retrospective study showed favorable effects for statins in SARS-CoV-2 infection. CONCLUSION: Patients with SARS-CoV-2 infection have a high risk of cardiovascular and thrombotic complications and pleiotropic effects of statins may help manage the COVID-19. There is growing evidence that supports the need for trials of statin treatment in COVID-19 infection.

Circulating and tissue microRNAs as a potential diagnostic biomarker in patients with thrombotic events.

Venous and arterial thrombosis are conditions that have a considerable burden if left untreated. The hypoxia-induced by the occluded vessel can disrupt the circulation of any organ, the cornerstone of treating thrombosis is rapid diagnosis and appropriate treatment. Diagnosis of thrombosis may be made by using laboratory tests or imaging techniques in individuals who have clinical manifestations of a thrombotic event. The use of serum micro ribonucleic acids (RNAs) has recently been applied to the diagnosis of thrombosis. These small RNA molecules are emerging as new diagnostic markers but have had very limited applications in vascular disease. Most of the articles provided various microRNAs with different levels of accuracy. However, there remains a lack of an appropriate panel of the most specific microRNA in the literature. The purpose of the present review was to summarize the existing data on the use of microRNAs as a diagnostic biomarker for venous thrombosis.

Selective serotonin reuptake inhibitors and cardiovascular events: A systematic review.

BACKGROUND: Given the importance of the role of depression in predicting the outcome of cardiovascular disorders, current medications for treating depression, particularly selective serotonin reuptake inhibitors (SSRIs), are taken into consideration. This study aimed to systematically review the published findings in the use of SSRIs and the risk for cardiac events. MATERIALS AND METHODS: An independent review of the Web of Science, PubMed, Scopus, Cochrane, CINAHL, index Copernicus, and Google Scholar, up to 2014, was performed. We identified studies evaluating the effect of SSRIs, on cardiovascular events. Articles in English with full text availability, review articles, and experimental studies were included in the study. Among 150 studies reviewed based on the included keywords, 17 met the study criteria and were finally reviewed. RESULTS: The use of some types of SSRIs may prevent platelet adhesion and aggregation; control the cardiovascular risk profile including hypertension, insulin resistance, and body weight; and also inhibit inflammatory processes. The appearance of adverse cardiac events, including cardiac arrhythmias (torsade de pointes and QT prolongation), syncope, increased systolic and diastolic right ventricular volume, and the production of pro-inflammatory cytokines leading atherosclerosis development, has also been expected with the chronic use of some types of SSRIs. CONCLUSION: According to our systematic review, both beneficial and adverse cardiovascular events can be established following the chronic use of various types of SSRIs. Therefore, when taking SSRIs, the cardiovascular effect of each SSRI has to be carefully considered, based on patients' cardiovascular risk profiles.

De Winter presentations and considerations: a case series.

BACKGROUND: The electrocardiogram has a critical role in the diagnosis and risk assessment of patients presenting with chest pain in the emergency ward. CASE PRESENTATION: We present 11 Iranian patients with diagnosis of de Winter referred to our center. Right coronary artery involvement was seen in four cases, left circumflex artery in three cases, proximal left anterior descending artery in two cases, and middle left anterior descending artery in seven cases. We present the case of a 52-year old Iranian male patient in detail. CONCLUSION: Recognizing the electrocardiogram of de Winter as an ST-elevation myocardial infarction equivalent in cases with suspected acute infarction is very important.

Managing Myocardial Infarction in the COVID-19 Epidemic: A Case Report.

Coronaviruses can cause viral pneumonia with extrapulmonary manifestations and complications. Many patients have either underlying cardiovascular disease or cardiac risk factors. Acute heart attacks are also frequent in severe cases of coronavirus disease 2019 (COVID-19), which is associated with high mortality. In this paper, we describe a patient with COVID-19 who presented with myocardial infarction (MI) symptoms but lacked the initial symptoms of the infection such as fever and cough. COVID-19 and myocardial infarction were diagnosed. The patient underwent thrombolytic treatment and fully recovered.

Wolff-Parkinson-White syndrome and de Winter patterns; An implication for paying special attention to electrocardiogram.

BACKGROUND: Despite recent advances in diagnostic techniques in cardiology, electrocardiography (ECG) has yet remained the first and corner stone of detecting emergency cardiac events including myocardial infarction (MI). There are some ECG findings which are considered as equivalents to MI. De Winter ST-T wave pattern is one of the important ECG findings which is thought to be related to left anterior descending artery occlusion. However, the coexistence of this ECG pattern with other ECG abnormalities are not reported widely. In this report, we discussed a unique case of de Winter ST-T wave pattern in a patient with Wolff-Parkinson-White (WPW) syndrome for the first time. CASE REPORT: A 43-year-old man was referred because of an intermittent typical chest pain. The patient had no cardiovascular risk factor, and was not on any medication; laboratory tests showed elevated and raising troponin I. The first ECG showed pre-excitation (WPW) as well as de winter pattern. According to patient's symptoms and suggestive ECG for probable left anterior descending (LAD) occlusion, emergent angiography was scheduled. The coronary angiography revealed sever LAD artery occlusion. The patient was symptom free after successful percutaneous coronary intervention, and was discharged on medication. The patient remained asymptomatic in 1-year follow-up period. CONCLUSION: Presence of de Winter ST-T changes with other ECG abnormalities is a rare issue, and here we addressed the first case of WPW and de Winter. The physicians should be aware that ECG changes in patients with WPW should not be interpreted as de Winter ST-T changes and vice versa.

QT interval and P wave dispersion in slow coronary flow phenomenon.

BACKGROUND: Slow coronary flow (SCF) phenomenon is an angiographic finding which is defined as slow contrast passage through coronary arteries which may predispose patients to serious cardiac complications such as fatal arrhythmias. P-wave and QT-interval dispersion are electrocardiographic findings which are related to atrial fibrillation and ventricular tachyarrhythmias. In the present study, the relation between SCF and presence of P-wave and QT-interval dispersion in electrocardiography has been evaluated. METHODS: 47 patients with normal coronary arteries and SCF and 40 patients with normal coronary artery flow without SCF were enrolled in this case control study. Standard electrocardiogram (ECG) was analyzed for P-wave and QT-interval dispersion. SCF was identified in normal coronary vessels by use of Thrombolysis in Myocardial Infarction (TIMI) frame count (TFC) method (TFC > 27). Corrected TIMI frame count (CTFC) of coronary vessels as well as mean CTFC along with QT-interval and P-wave dispersion were compared between 2 groups. The study data were analyzed by SPSS software and P value less than 0.050 was considered to be significant. RESULTS: QT-interval [76.17 (35.23) ms versus 39.25 (19.26) ms] and P-wave [39.74 (17.48) ms versus 19.50 (8.54) ms] dispersion were significantly higher among patients with SCF phenomenon (P < 0.050). In addition, there was a positive significant linear correlation between TFC and P-wave and QT-dispersion (r = 0.857, r = 0.861, respectively, P < 0.050). CONCLUSION: According to the results, increasing TFC among patients with SCF will result in P wave and QT interval dispersion and therefore this finding can be considered as an indicative marker for cardiac events.

Anomalous Intercoronary Communication with Unidirectional Flow in the Absence of Obstructive Coronary Artery Disease: A Case Report.

Large intercoronary communications in the absence of obstructive coronary artery disease constitute a very rare coronary artery anomaly in which there is a readily visible connection between the 2 coronary arteries with a unidirectional or bidirectional blood flow; consequently, this anomaly may be misinterpreted as a functioning collateral vessel, indicative of an unrecognized proximal coronary artery occlusion. In contrast to collateral vessels that are seen in the presence of critical coronary artery stenosis and total occlusions, these arterial communications are vessels that are single, extramural, straight, and large in diameter. Myocardial ischemia could result from the coronary steal phenomenon by a unidirectional intercoronary communication. Herein, we describe a 57-year-old female with chest pain who was found in coronary angiography to have a single large intercoronary channel between the posterolateral branch of the right coronary artery and the distal left circumflex artery with a unidirectional flow.

Echocardiographic characteristics of isolated left ventricular noncompaction.

BACKGROUND: Although isolated left ventricular noncompaction (ILVNC) has been described almost two decades ago, our knowledge about its diagnosis, presentation, echocardiographic features and clinical outcome is sparse. We aimed to assess the echocardiographic and clinical characteristics of ILVNC in a group of patients referred to our center. METHODS: Patients who were referred to a tertiary referral center, affiliated with Mashhad University of Medical Sciences, with primary diagnosis of dilated cardiomyopathy underwent comprehensive echocardiographic evaluation. The diagnosis of ILVNC was made based on the presence of two-structural layer in myocardium; ratio of noncompacted to compacted layers more than 2, and excessive trabeculation in the left ventricle. RESULTS: Final diagnoses of ILVNC were made in 42 patients. Mean age of patients was 32.9 ± 15.6 years (ranging from 9 to 70 years). Females comprised a higher proportion of patients (61.9%) and shortness of breath was the most reported symptom among patients (47.6%). Non-compacted layers were detected in inferior and lateral segments of apex in 97.6% of patients. A total of 26 (61.9%) patients had left ventricle (LV) dysfunction (defined as ejection fraction less than 50%). The only factor that showed significant association with LV dysfunction was the number of affected segments with noncompaction (P = 0.008). Reduced ejection fraction was not associated with either age or sex (P = 0.437 and P = 0.206, respectively). CONCLUSION: Based on the result of the current study, it can be suggested that apex of the heart is the most common site of noncompaction and increasing numbers of affected segments might be associated with LV dysfunction.

Left ventricular apical hypoplasia: Case report on cardiomyopathy and a history of sudden cardiac death.

BACKGROUND: Isolated left ventricular apical hypoplasia with several different unrecognized dimensions is a newly discovered congenital anomaly of the heart. CASE REPORT: In this report, we describe a case of cardiomyopathy of this type occurring in a 13-year-old male with a history of mental retardation and sudden cardiac death (SCD) of second-degree relatives. The patient was referred for an evaluation of cardiac status. An echocardiography analysis demonstrated a spherical left ventricle (LV) appearance with mild mitral regurgitation. Cardiac magnetic resonance imaging (MRI) confirmed a spherical and truncated LV appearance. The right ventricle was found to have elongated and wrapped around the LV, and diverticulum was also seen in the cardiac MRI. CONCLUSION: To the best of our knowledge, this is to present the first case of LV apical hypoplasia combined with LV diverticulum and a family history of SCD. As more cases featuring this cardiomyopathy type are recognized, it will be easier to elucidate the natural history and management of such cardiac anomalies.

Congenital partial absence of the pericardium presenting with a rare concurrent abnormality of vascular ring diagnosed by cardiac magnetic resonance imaging.

Congenital absence of the pericardium is a rare abnormality that can be diagnosed by cardiac imaging procedures. A 49-year-old male needed medical attention due to the appearance of palpitation with a systolic murmur, and a notable aortic arch deviation was seen in the chest X-ray. In the echocardiogram, a poor echo window was detected. A cardiac magnetic resonance imaging (MRI) showed a rare concomitant anomaly of partial absence of the pericardium including a rare defect of the right-sided aortic arch. Using cardiac MRI, the pericardium can be easily visualized, and thus, its absence more easily detected, aiding appropriate clinical decision-making.

Pentoxifylline and prevention of contrast-induced nephropathy: Is it efficient in patients with myocardial infarction undergoing coronary angioplasty?

BACKGROUND: Contrast-induced nephropathy (CIN) is a major concern following procedures with applying iodinated contrast media. The basis prevention of CIN is hydration and to avoid hypovolemia. We aimed to evaluate the efficacy of pentoxifylline (PTX) for the prevention of CIN in patients with myocardial infarction (MI) undergoing coronary angioplasty. METHODS: This prospective, single-blind, randomized clinical trial study was performed on 175 (127 men) of MI patients undergoing routine treatment. Patients were assigned randomly to the control (n = 84) and study groups (n = 91). In our study group, patients received 400 mg/3 times a day from 24 hours before to 24 hours after coronary angiography. In addition, before the procedure and after 48 hours from the procedure, serum creatinine was measured. RESULTS: CIN occurred in 14 patients (8.0%); 8 controls (9.5%) and 6 patients (6.6%) in the PTX group )P = 0.475) showing PTX to have no significant effect on CIN [P = 0.750, odds ratio = 0.82 (confidence interval = 0.24-2.8)] though a significantly different volume of contrast was used between the groups (231.29 ± 105.10 mm3 and 190.88 ± 75.82 mm3; P = 0.005, respectively). CONCLUSION: There was no significantly different occurrence of CIN on patients with MI, undergoing coronary angioplasty, but its relatively lower rate in PTX group would recommend the prophylactic oral use of PTX for CIN prevention.

Antidepressants and cardiovascular adverse events: A narrative review.

BACKGROUND: Major depression or deterioration of previous mood disorders is a common adverse consequence of coronary heart disease, heart failure, and cardiac revascularization procedures. Therefore, treatment of depression is expected to result in improvement of mood condition in these patients. Despite demonstrated effects of anti-depressive treatment in heart disease patients, the use of some antidepressants have shown to be associated with some adverse cardiac and non-cardiac events. In this narrative review, the authors aimed to first assess the findings of published studies on beneficial and also harmful effects of different types of antidepressants used in patients with heart diseases. Finally, a new categorization for selecting antidepressants according to their cardiovascular effects was described. METHODS: Using PubMed, Web of Science, SCOPUS, Index Copernicus, CINAHL, and Cochrane Database, we identified studies designed to evaluate the effects of depression and also using antidepressants on cardiovascular outcome. A 40 studies were finally assessed systematically. Among those eligible studies, 14 were cohort or historical cohort studies, 15 were randomized clinical trial, 4 were retrospective were case-control studies, 3 were meta-analyses and 2 animal studies, and 2 case studies. RESULTS: According to the current review, we recommend to divide antidepressants into three categories based on the severity of cardiovascular adverse consequences including (1) the safest drugs including those drugs with cardio-protective effects on ventricular function, as well as cardiac conductive system including selective serotonin reuptake inhibitors, (2) neutralized drugs with no evidenced effects on cardiovascular system including serotonin-norepinephrine reuptake inhibitors, and (3) harmful drugs with adverse effects on cardiac function, hemodynamic stability, and heart rate variability including tricyclic antidepressants, serotonin antagonist and reuptake inhibitors, and noradrenergic and specific serotonergic antidepressants. CONCLUSION: The presented categorization of antidepressants can be clinically helpful to have the best selection for antidepressants to minimizing their cardiovascular harmful effects.

Acute myocardial infarction in a young male wrestler: A case report.

BACKGROUND: Anabolic steroids have been widely used in recent years. It could adversely affect the cardiovascular system. Non-traditional risk factors for coronary heart diseases (CHDs) have raised great concern. CASE REPORT: A young bodybuilder was presented with crushing retrosternal chest pain, excessive diaphoresis, and vomiting. The symptoms began during wrestling. The patient did not have a history of traditional cardiovascular risk factors. He was using large quantities of nutritional and bodybuilding supplements with multiple intramuscular injections of dexamethasone during past 6 months. The electrocardiography (ECG) revealed ST-segment elevation in the precordial, I and aVL leads consistent with acute extensive myocardial infarction (MI). Lipid profile, cardiac troponin, and creatine phosphokinase-MB (CPK-MB) was abnormal. Transthoracic echocardiography (TTE) revealed mild left ventricular (LV) enlargement and reduced global systolic dysfunction with regional wall akinesia. The patient received thrombolytic therapy which was resulted in symptomatic relief and resolution in ST-T changes. Significant smoke was seen in LV cavity without clot formation on the discharge day. About 1 week later, large fresh clots were seen in the apex. He was admitted again, and the burden of clots was reduced significantly after initiation of oral warfarin. Other laboratory tests were as follows: High-sensitivity C-reactive protein (CRP): 25.9 mg/dl, homocysteine: 26.2 µmol/l. The patient was discharged with specific medication. Clots were disappeared after 6 weeks of warfarin therapy. Later, the patient was evaluated again, and there was not any symptom and LV clots. CONCLUSION: Hyperhomocysteinemia could be induced by steroid abuse and may cause atherosclerotic and thrombotic effects in healthy athletes. We suggest clinicians to take a careful history of young athletes presented with MI or thrombotic events and also pay special attention to their homocysteine levels in their follow-ups.

Nicorandil Versus Nitroglycerin for Symptomatic Relief of Angina in Patients With Slow Coronary Flow Phenomenon: A Randomized Clinical Trial.

OBJECTIVE: Patients with the coronary slow flow phenomenon frequently experience angina episodes. The present study aimed to compare the efficacy of nicorandil versus nitroglycerin for alleviation of angina symptoms in slow flow patients. METHODS: In a single-center, single-blind, parallel-design, comparator-controlled, randomized clinical trial (NCT02254252), 54 patients with slow flow and normal or near-normal coronary angiography who presented with frequent angina episodes were randomly assigned to 1-month treatment with nicorandil 10 mg, 2 times a day (n = 27) or sustained-release glyceryltrinitrate 6.4 mg 2 times a day (n =27). Frequency of angina episodes, pain intensity, and the Canadian Cardiovascular Society (CCS) grading of angina pectoris were assessed at baseline and after 1 month of treatment. RESULTS: In all, 25 patients in the nicorandil arm and 24 patients in the nitroglycerin arm were analyzed. After 1 month, patients treated with nicorandil had fewer angina episodes (adjusted mean number of episodes per week, nicorandil versus nitroglycerin; 1.68 ± 0.15 vs 2.29 ± 0.15, P = .007, effect size = 14.6%). Patients also reported greater reductions in pain intensity with nicorandil versus nitroglycerin (adjusted mean of self-reported pain score; 3.03 ± 0.29 vs 3.89 ± 0.30, P = .046, effect size = 8.4%). A significantly higher proportion of patients in the nicorandil arm were categorized in CCS class I (76% vs 33.3%, P = .004) or class II (16.0% vs 45.8%, P = .032). CONCLUSION: In slow flow patients, nicorandil provides better symptomatic relief of angina than nitroglycerin.

Giant idiopathic pulmonary artery aneurysm: an interesting incidental finding.

Idiopathic pulmonary artery aneurysm is a rare condition. This type of aneurysm can be presented with noncardiac symptoms or even asymptomatic. We report a 73-year-old man with a gigantic idiopathic pulmonary artery aneurysm which was referred to our unit for his kidney problems. During his workup we incidentally found the aneurysm by an abnormal chest-X ray and auscultation. Our further evaluations revealed a 9.8 cm aneurysm in transthoracic echocardiography.