An Index for Evaluating Exercise Capacity Improvement After Cardiac Rehabilitation in Patients After Myocardial Infarction.

OBJECTIVE: We investigated relationships among predictors of improvement in exercise capacity after cardiac rehabilitation programs in patients after acute myocardial infarction. METHODS: We carried out a secondary analysis of data from 41 patients with a left ventricular ejection fraction ≥ 40% who underwent cardiac rehabilitation after the first myocardial infarction. Participants were assessed using a cardiopulmonary exercise test and stress echocardiography. A cluster analysis was performed, and the principal components were analyzed. RESULTS: Two distinct clusters with significantly different ( P = .005) proportions of response to treatment (peak VO 2 ≥ 1 mL/kg/min) were identified among patients. The first principal component explained 28.6% of the variance. We proposed an index composed of the top 5 variables from the first component to represent the improvement in exercise capacity. The index was the average of scaled O 2 uptake and CO 2 output at peak exercise, minute ventilation at peak, load achieved at peak exercise, and exercise time. The optimal cutoff for the improvement index was 0.12, which outperformed the peak VO 2 ≥ 1 mL/kg/min criterion in recognizing the clusters, with a C-statistic of 91.7% and 72.3%, respectively. CONCLUSION: The assessment of change in exercise capacity after cardiac rehabilitation could be improved using the composite index.

Evaluation of the efficacy of signal-averaged electrocardiogram testing in the cardiac assessment of beta-thalassemia major patients.

BACKGROUND: More than 70% of thalassemia's major mortality is due to the cardiac complications of this syndrome, mostly consequent to myocardial Iron overload; therefore, evaluation of such complications is of utmost importance. T2*MRI is used to assess hepatic and myocardial Iron load in thalassemia patients, which is not always available. Signal-Averaged Electrocardiography is a rather easy method of evaluating major thalassemia patients regarding their risk for sudden cardiac death. METHODS AND MATERIALS: In this cross-sectional study, 48 patients with thalassemia major underwent evaluation with electrocardiography, signal-averaged electrocardiography, echocardiography, T2*MRI, and ferritin level. The association of the existence of ventricular late potentials in SAECG and other cardiac variables was evaluated. Moreover, the association between myocardial and hepatic Iron load and cardiac characteristics was assessed. RESULTS: 48 patients with a mean age of 30.31 ± 7.22 years old entered the study. 27 (56.3%) of the patients had ventricular late potentials, which were associated with myocardial dry Iron weight (P = 0.011). Nonspecific ST-T changes and premature atrial and ventricular contractions were seen more frequently in patients with late potentials (P = 0.002, 0.031, and 0.031, respectively). Patients with higher myocardial and hepatic Iron loads had longer QTc in their 12-lead surface electrocardiograms. CONCLUSION: Patients with ventricular late potentials assessed by SAECG had a higher myocardial Iron load. Higher myocardial Iron load is associated with higher cardiac complications in patients with beta-thalassemia major; therefore, SAECG can be used as a screening test for cardiac complications in beta-thalassemia major patients.

The association of stroke risk factors with the future thickness of carotid atherosclerotic plaques.

OBJECTIVES: An advancing atherosclerotic plaque is a risk factor for stroke. We conducted this study to assess the relationship between risk factors of stroke with changing in the thickness of carotid plaques thickness evident on sonography. METHODS: We carried out a secondary analysis of data from a study on carotid bifurcation plaques. Data were collected in the sonography laboratories of two university hospitals. In total, 564 (240; 42.6% men) patients with atherosclerotic plaques in the carotid bifurcation and internal carotid artery with stenosis ≥ 30% evident on duplex sonography were included. We developed machine learning models using an extreme gradient boosting algorithm with Shapley additive explanation method to find important risk factors and their interactions. The outcome was a change in the carotid plaque thickness after 36 months, and the predictors were initial plaque thickness and the risk factors of stroke. RESULTS: Two regression models were developed for left and right carotid arteries. The R-squared values were 0.964 for the left, and 0.993 for the right model. Overall, the three top features were BMI, age, and initial plaque thickness for both left and right plaques. However, the risk factors of stroke showed stronger interaction in predicting plaque thickening of the left carotid more than the right carotid artery. DISCUSSION: The effect of each predictor on plaque thickness is complicated by interactions with other risk factors, particularly for the left carotid artery. The side of carotid artery involvement should be considered for stroke prevention.

Is it the Time to Move Towards Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve Guided Percutaneous Coronary Intervention? The Pros and Cons.

Coronary artery disease is the leading cause of mortality worldwide. Diagnosis is conventionally performed by direct visualization of the arteries by invasive coronary angiography (ICA), which has inherent limitations and risks. Measurement of fractional flow reserve (FFR) has been suggested for a more accurate assessment of ischemia in the coronary artery with high accuracy for determining the severity and decision on the necessity of intervention. Nevertheless, invasive coronary angiography-derived fractional flow reserve (ICA-FFR) is currently used in less than one-third of clinical practices because of the invasive nature of ICA and the need for additional equipment and experience, as well as the cost and extra time needed for the procedure. Recent technical advances have moved towards non-invasive high-quality imaging modalities, such as magnetic resonance, single-photon emission computed tomography, and coronary computed tomography (CT) scan; however, none had a definitive modality to confirm hemodynamically significant coronary artery stenosis. Coronary computed tomography angiography (CCTA) can provide accurate anatomic and hemodynamic data about the coronary lesion, especially calculating fractional flow reserve derived from CCTA (CCTA-FFR). Although growing evidence has been published regarding CCTA-FFR results being comparable to ICA-FFR, CCTA-FFR has not yet replaced the invasive conventional angiography, pending additional studies to validate the advantages and disadvantages of each diagnostic method. Furthermore, it has to be identified whether revascularization of a stenotic lesion is plausible based on CCTA-FFR and if the therapeutic plan can be determined safely and accurately without confirmation from invasive methods. Therefore, in the present review, we will outline the pros and cons of using CCTA-FFR vs. ICA-FFR regarding diagnostic accuracy and treatment decision-making.

Role of A Single Nucleotide Polymorphism in Thrombospondine 4 Gene in Premature Myocardial Infarction among Population of Southern Iran.

BACKGROUND: Coronary Artery Diseases (CAD) are the leading cause of Myocardial Infarction (MI). However, their underlying etiology can be found in the interplay between environmental and genetic factors. On the other hand, it has been shown that Extracellular Matrix (ECM) proteins, such as Thrombospondins (TSP), play a crucial regulatory role in vascular pathologies, including atherogenesis. TSPs are extracellular proteins responsible for intercellular and cell-ECM interactions and are involved in regulating functional responses. Recently, a missense mutation in the TSP-4 gene has been reported to potentially increase the risk of CADs. The present study aimed to investigate the role of rs1866389 Guanosine to Cytosine (G/C) Single Nucleotide Polymorphism (SNP) of the TSP-4 gene on the prevalence of premature MI in southern Iran. METHOD: The present case-control study included 100 patients with premature MI and 100 healthy individuals. The DNA extracted from the blood samples of the participants underwent Polymerase Chain Reaction (PCR) for the sequence of the TSP-4 gene. Afterward, the frequency of C (mutated) and G (normal) alleles of the TSP-4 gene was evaluated in the case and control groups. RESULTS: According to our findings, there was no significant intergroup difference in gender, age, and smoking status. However, the case group was significantly higher in the prevalence of Diabetes mellitus (DM), Hyperlipidemia (HLP), and Hypertension (HTN) compared to the control group. Moreover, 22%, 49%, and 29% of the case group had CC, GC, and GG genotypes in the TSP-4 gene, respectively, while the prevalence of CC, GC, and GG genotypes were 10%, 44%, and 46% in the control group. Also, the prevalence of allele C was significantly higher in the case group (47%) compared to the control group (33%, P=0.043), showing its significant association with the increased risk of premature MI (OR = 1.80; 95% CI = 1.01-3.19). CONCLUSIONS: The rs1866389 G/C SNP of the TSP-4 gene significantly increased the risk of premature MI in the population of southern Iran. Thus, such mutated gene can be used as a target for gene therapy or a marker for early detection of individuals at high risk for CADs.

Advancing prognostic precision in pulmonary embolism: A clinical and laboratory-based artificial intelligence approach for enhanced early mortality risk stratification.

BACKGROUND: Acute pulmonary embolism (PE) is a critical medical emergency that necessitates prompt identification and intervention. Accurate prognostication of early mortality is vital for recognizing patients at elevated risk for unfavourable outcomes and administering suitable therapy. Machine learning (ML) algorithms hold promise for enhancing the precision of early mortality prediction in PE patients. OBJECTIVE: To devise an ML algorithm for early mortality prediction in PE patients by employing clinical and laboratory variables. METHODS: This study utilized diverse oversampling techniques to improve the performance of various machine learning models including ANN, SVM, DT, RF, and AdaBoost for early mortality prediction. Appropriate oversampling methods were chosen for each model based on algorithm characteristics and dataset properties. Predictor variables included four lab tests, eight physiological time series indicators, and two general descriptors. Evaluation used metrics like accuracy, F1_score, precision, recall, Area Under the Curve (AUC) and Receiver Operating Characteristic (ROC) curves, providing a comprehensive view of models' predictive abilities. RESULTS: The findings indicated that the RF model with random oversampling exhibited superior performance among the five models assessed, achieving elevated accuracy and precision alongside high recall for predicting the death class. The oversampling approaches effectively equalized the sample distribution among the classes and enhanced the models' performance. CONCLUSIONS: The suggested ML technique can efficiently prognosticate mortality in patients afflicted with acute PE. The RF model with random oversampling can aid healthcare professionals in making well-informed decisions regarding the treatment of patients with acute PE. The study underscores the significance of oversampling methods in managing imbalanced data and emphasizes the potential of ML algorithms in refining early mortality prediction for PE patients.

Monster left circumflex artery fistula closure by vascular plug in a patient with post-COVID-19 myocardial infarction.

Herein, we report a man with a huge coronary fistula connecting the left circumflex coronary artery to the right ventricle. During the follow-up, the patient developed progressive symptoms of heart failure nonresponsive to medical treatment. Therefore, an endovascular closure with a vascular plug was successfully done for him. Transcatheter vascular plug occlusion can be considered as an alternative for closure of symptomatic high-flow large coronary artery fistulas in patients with a high risk of surgery and chance of coil dislocation, embolization, or unavailability of proper coils.

Diagnosis of Simultaneous Atrial and Ventricular Mechanical Performance in Patients with Systemic Sclerosis.

Objective: Cardiac involvement is a predictor of poor prognosis in patients with systemic sclerosis (SSc); therefore, preclinical diagnosis of heart involvement is crucial. Two-dimensional speckle tracking echocardiography (2D-STE), a method for evaluating the myocardial strain, could be helpful for the early diagnosis of cardiac mechanical function abnormalities. In this study, the simultaneous evaluation of all cardiac chambers was studied in patients with SSc, compared with normal individuals. Methods: The results of transthoracic echocardiography (TTE) and 2D-STE of 37 patients with SSc and 37 healthy individuals and the longitudinal strain (LS) of all chambers was precisely evaluated. The collected data were analyzed using SPSS version 16, and independent-sample t test and Chi-square test were used for comparison between the groups. Results: The mean ± SD of the participants' age was 45.7 ± 11.54 (range of 17 to 68) years; most of them were women (75.7%). TTE showed higher left atrial (LA) volume (p < 0.001), right atrial (RA) area (p = 0.007), the severity of ventricular dysfunction (p < 0.05) and inferior vena cava diameter (p = 0.005), compared with the control group. Spectral and tissue Doppler echocardiography showed higher systolic pulmonary arterial pressure (sPAP) and mitral A wave velocity, and lower E/A ratio, E' velocity of left ventricular (LV) septal and lateral wall in the case group (p < 0.05). Color Doppler echocardiography showed a higher frequency of valvular regurgitation in the case group (p < 0.05). The results of 2D-STE showed lower LA roof LS (p < 0.001), LA average LS (p = 0.015), LA global LS (p = 0.028), and LA ejection fraction (LAEF) (p = 0.001), lower mean RA left wall (p = 0.048) and EF (p < 0.001), and higher RV global LS in the case group (p = 0.025). Conclusions: Simultaneous evaluation of all cardiac chambers by 2D-STE provides valuable information about the myocardial involvement in patients with SSc. Therefore, it is suggested to use this method for the early diagnosis of cardiac involvement in such patients.

Cellulite: Presentation and management.

BACKGROUND: Cellulite is a common dermatological condition with a female preponderance, affecting up to 90% post-pubertal females. It is characterized with dimpling and denting of the skin surface, giving it a Peau d'orange appearance. Once considered to be a benign physiological isolated skin condition of only an esthetic concern, cellulite is now considered a pathological entity with systemic associations and a negative psychological impact on patients. AIMS: The objective of this article was to discuss etiology, pathophysiology, and treatment of cellulite. MATERIALS AND METHODS: Literature was screened to retrieve articles from PubMed/Medline and Google Scholar and related websites. Cross-references from the relevant articles were also considered for review. Review articles, clinical studies, systematic reviews, meta-analysis, and relevant information from selected websites were included. RESULTS: Several treatment options from lifestyle modifications and topical cosmetic therapies to energy-based devices have been studied for its treatment. However, treatment remains a challenge despite many new modalities in the armamentarium. Laser and light therapies along with radiofrequency are useful treatment options with good safety profile. Acoustic wave therapy, subcision, and 1440-nm Nd:YAG minimally invasive laser are beneficial in cellulite reduction. DISCUSSION: Methodological differences in the trials conducted make it difficult to compare different treatment modalities. CONCLUSION: Overall, treatment needs to be individualized based on the patient characteristics and severity of the condition. A combination of treatments is often required in most patients for reducing cellulite.

Can SARS-CoV-2 vaccine increase the risk of reactivation of Varicella zoster? A systematic review.

INTRODUCTION: Although the COVID-19 vaccination is deemed safe, exact incidence and nature if adverse effects, particularly dermatological ones, are still unknown. OBJECTIVE: To describe the demographic, clinical, morphological characteristics, outcomes, and timing of development of herpes zoster to the various COVID-19 vaccines. And to identify on whether COVID-19 vaccine has temporal relationship between development of herpes zoster (HZ). METHODS: We have performed a systemic review of articles from PubMed and Embase using MeSH and keywords like "Shingles," "Herpes zoster," "Varicella zoster," "COVID-19," "Vaccine," "SARS-CoV-2." No filters including country of publication, language, type of articles were applied. Individual case report references were filtered for any pertinent cases. RESULTS: A total of 54 cases consisting of 27 male and 27 female patients have been reported. There were cases with known risk factors for herpes zoster, which included age more than 50 years (n = 36), immunological disorders (n = 10), chronic disease (n = 25), metabolic disorder (n = 13), malignancy (n = 4), and psychiatric disorder (n = 2). The mean (SD) period between development of herpes zoster and COVID-19 vaccination was 7.64 (6.92) days. Majority of the cases were from the high-income and/or middle-income countries. 86.27% of the cases of HZ were reported due to mRNA vaccine. Thirty-six patients 36/45 (80%) developed herpes zoster following the priming dose of COVID-19 vaccine among those who received mRNA vaccine. CONCLUSION: We could not establish definite link but there may be possible association between COVID-19 vaccine and shingles. Large-scale studies may help to understand the cause-effect relationship.