Evaluating the role of intravenous pentoxifylline administration on primary percutaneous coronary intervention success rate in patients with ST-elevation myocardial infarction (PENTOS-PCI).

Ischemia reperfusion injury can lead to further myocardiocyte damage in patients with ST-elevation myocardial infarction (STEMI). Pentoxifylline is a methylxanthine derivative with known anti-inflammatory, antioxidant, vasodilator, and rheological properties which can be a promising agent in preventing reperfusion injury. PENTOS-PCI is a single-center, randomized, double-blind, placebo-controlled trial which evaluated the efficacy and safety of preprocedural administration of intravenous pentoxifylline in patients undergoing primary percutaneous coronary intervention (PCI). Patients with acute STEMI who were eligible for PCI were randomized to receive either 100-mg intravenous infusion of pentoxifylline or placebo, prior to transferring to catheterization laboratory. Overall, 161 patients were included in our study of whom 80 patients were assigned to pentoxifylline and 81 to the control groups. Per-protocol analysis of primary endpoint indexing PCI's success rate as measured by thrombolysis in myocardial infarction (TIMI) flow grade 3 was not significantly different between pentoxifylline and placebo (71.3% and 66.3% respectively, P = 0.40). In addition, pentoxifylline could not improve secondary angiographic endpoints including myocardial blush grade 3 (87.5% and 85.2%, P = 0.79) and corrected TIMI frame count (22.8 [± 9.0] and 24.0 [± 5.1], P = 0.33) in the intervention and placebo groups respectively. The rates of major adverse cardiac and treatment emergent adverse effects were not significantly different between the two groups. Administration of intravenous pentoxifylline before primary PCI did not improve the success rate of the procedure in patients with STEMI. Intravenous administration of pentoxifylline was well tolerated, and there were no significant differences regarding adverse drug reactions in the two groups. Panel A, background: pentoxifylline is a methylxanthine derivative with known anti-inflammatory, antioxidant, vasodilator, and rheological properties which can be a promising agent in preventing reperfusion injury. Panel B: study design and main results of the PENTOS-PCI trial. cTFC corrected TIMI frame count, ED emergency department, IRI ischemia reperfusion injury, MBG myocardial blush grade, PCI percutaneous coronary intervention, PPCI primary PCI, PTX pentoxifylline, ROS reactive oxygen species, SD standard deviation, STEMI ST-elevation myocardial infarction, TIMI thrombolysis in myocardial infarction.

Factor V Leiden but not the factor II 20210G>A mutation is a risk factor for premature coronary artery disease: a case-control study in Iran.

Background: Factor V Leiden (FVL) and factor II c.∗97G>A (rs1799963) are genetic risk factors for venous thromboembolism. Their contribution to coronary artery disease (CAD) is less clear. Objectives: This study aimed to investigate the association between FVL, rs1799963, and premature CAD in Iranians. Methods: We performed a genetic case-control study of 944 cases and 1081 controls from the premature CAD Milano-Iran study, including patients aged 18-55 (female) and 18-45 years (male) who underwent coronary angiography at the Tehran Heart Centre (Iran) in 2004-2011. Cases had luminal stenosis ≥50% in at least 1 main coronary artery or branch. Controls were age- and sex-matched with no CAD history. FVL and rs1799963 were genotyped using TaqMan SNP genotyping assays. Association was tested by logistic regression adjusted for matching factors and ethnicity. Effect modification by sex and cardiovascular risk factors (metabolic [obesity, hypertension, hyperlipidemia, and diabetes], and smoking) was assessed. Results: The risk of premature CAD was increased by 50% in FVL carriers (adjusted odds ratio [adjOR] 1.54 [95% CI, 0.95-2.48]) and slightly reduced in rs1799963 carriers (adjOR 0.71 [95% CI, 0.40-1.27]). These effects were more pronounced in women than men (FVL, adjOR 1.66 vs 1.25; rs1799963, adjOR 0.60 vs 1.07). The risk of premature CAD was substantially increased in carriers of FVL with at least 1 metabolic risk factor compared with noncarriers without metabolic risk factors (adjOR 25.14 [95% CI, 12.51-50.52]). Conclusion: FVL but not FII rs1799963 was associated with an increased risk of CAD in young Iranians. This risk increased considerably when combined with metabolic cardiovascular risk factors.

In-hospital and 1-year outcomes of patients without modifiable risk factors presenting with acute coronary syndrome undergoing PCI: a Sex-stratified analysis.

Aim: A considerable proportion of patients admitted with acute coronary syndrome (ACS) have no standard modifiable cardiovascular risk factors (SMuRFs: hypertension, diabetes mellitus, dyslipidemia, and cigarette smoking). The outcomes of this population following percutaneous coronary intervention (PCI) are debated. Further, sex differences within this population have yet to be established. Methods: This retrospective cohort study included 7,847 patients with ACS who underwent PCI. The study outcomes were in-hospital mortality, all-cause mortality, and major adverse cardio-cerebrovascular events (MACCE). The association between the absence of SMuRFs (SMuRF-less status) and outcomes among all the patients and each sex was assessed using logistic and Cox proportional hazard regressions. Results: Approximately 11% of the study population had none of the SMuRFs. During 12.13 [11.99-12.36] months of follow-up, in-hospital mortality (adjusted-odds ratio (OR):1.51, 95%confidence interval (CI): 0.91-2.65, P:0.108), all-cause mortality [adjusted-hazard ratio (HR): 1.01, 95%CI: 0.88-1.46, P: 0.731], and MACCE (adjusted-HR: 0.93, 95%CI:0.81-1.12, P: 0.412) did not differ between patients with and without SMuRFs. Sex-stratified analyses recapitulated similar outcomes between SMuRF+ and SMuRF-less men. In contrast, SMuRF-less women had significantly higher in-hospital (adjusted-OR: 3.28, 95%CI: 1.92-6.21, P < 0.001) and all-cause mortality (adjusted-HR:1.41, 95%CI: 1.02-3.21, P: 0.008) than SMuRF+ women. Conclusions: Almost one in 10 patients with ACS who underwent PCI had no SMuRFs. The absence of SMuRFs did not confer any benefit in terms of in-hospital mortality, one-year mortality, and MACCE. Even worse, SMuRF-less women paradoxically had an excessive risk of in-hospital and one-year mortality.

Effect of postoperative atrial fibrillation on early and mid-term outcomes of coronary artery bypass graft surgery.

OBJECTIVES: The long-term prognostic role of postoperative atrial fibrillation (POAF) in cardiovascular outcomes in patients undergoing cardiac surgery is uncertain. Our goal was to investigate the impact of new-onset POAF on midterm adverse cardiovascular events after coronary artery bypass graft (CABG) surgery. METHODS: We performed a retrospective cohort study of patients who underwent isolated CABG without a preoperative history of atrial fibrillation/flutter. POAF was defined as episodes of AF lasting ≥30 s during the hospitalization period. The effect of POAF on midterm all-cause mortality and cerebrovascular accidents/transient ischaemic attacks (CVA/TIA) was assessed using a Cox proportional hazard regression model in a competing risk setting. Additional analyses were performed on patients surviving an event-free early postoperative period (i.e. within 30 postoperative days after the index operation). RESULTS: A total of 9,310 patients were followed for a median duration of 48.7 months. New-onset POAF was associated with an increased risk of midterm all-cause mortality (HR = 1.648, 95% confidence interval: 1.402-1.937; P < 0.001) and CVA/TIA (subdistribution-HR = 1.635, 1.233-2.167; P = 0.001). After excluding patients who died during the early postoperative period, POAF remained significantly associated with higher late all-cause mortality (HR = 1.518, 1.273-1.811; P < 0.001). However, the risk of late CVA/TIA in patients who survived the early postoperative period without having a stroke was similar between those with and without POAF (subdistribution-HR = 1.174, 0.797-1.729; P = 0.418). CONCLUSIONS: New-onset POAF after CABG is associated with an increased risk of midterm overall mortality and stroke. However, late stroke risk is likely similar between patients with and without POAF who survive an event-free early postoperative period.

Intramyocardial echo-free space with a turbulent flow within, suggestive of an aneurysmal coronary artery.

Coronary artery aneurysms are well known, and intramyocardial coronary artery aneurysms comprise a rare type of this condition. This case image presents an incidentally detected intramyocardial aneurysm in the left anterior descending artery of a 32-year-old man with atypical chest pain evaluated by multimodality imaging. The presence of an intramyocardial echo-free space may flag up this condition.

Outcome of Percutaneous Coronary Intervention in Old Patients Presenting with Acute Coronary Syndrome.

BACKGROUND: Octogenarians (age≥80 years) with coronary artery disease constitute a high-risk group and the elderly undergoing percutaneous coronary intervention (PCI) are at higher risk of adverse outcomes compared to young patients. In this study, we aimed to describe the outcomes of the elderly with acute coronary syndrome (ACS) who underwent PCI and also to identify the predictors of short-term major adverse cerebrocardiovascular events (MACCE) in octogenarians. METHODS: In this registry-based cohort study, we reviewed the data of patients (aged≥65 years) who underwent PCI. Univariate Cox-regression model was used to assess the univariate effects of covariates on mortality and MACCE and multivariate Cox-regression analysis were used to discover MACCE predictors. RESULTS: We reviewed the data of 3332 patients (2722 elderly [65 to 79 years], and 610 octogenarians [≥80 years]). The cumulative hazard of MACCE was significantly higher in the octogenarian group compared with the younger group (P<0.001). MACCE in octogenarians presenting with ST-elevation myocardial infarction (STEMI) was significantly higher than those with non-ST-elevation myocardial infarction/Unstable angina (NSTEMI/UA) (P<0.001); however, the cumulative hazard of mortality was not significantly different between the two groups (P=0.270). Successful PCI, left main stenosis and estimated glomerular filtration rate (eGFR) were independent predictors of MACCE in octogenarians with ACS. CONCLUSION: Octogenarians undergoing PCI had a higher rate of MACCE and mortality compared with a younger population. In octogenarians, MACCE in those with STEMI was significantly higher than those with NSTEMI/UA and the mortality trend was similar; however, the 1-year trend was in favor of the STEMI subgroup.

Prevalence and trends of coronary artery disease risk factors and their effect on age of diagnosis in patients with established coronary artery disease: Tehran Heart Center (2005-2015).

BACKGROUND: Coronary artery disease (CAD) is a universal public health challenge, more prominently so in the low- and middle-income countries. In this study, we aimed to determine prevalence and trends of CAD risk factors in patients with documented CAD and to determine their effects on the age of CAD diagnosis. MATERIALS AND METHODS: We conducted a registry-based, serial cross-sectional study using the coronary angiography data bank of the Tehran Heart Center. Adult patients who had obstructive (> 50% stenosis) CAD were included in the study. The prevalence and 11-year trends of conventional CAD risk factors were analyzed by sex and age, and their adjusted effects on the age of CAD diagnosis were calculated. RESULTS: From January 2005 to December 2015, data for 90,094 patients were included in this analysis. A total of 61,684 (68.5%) were men and 28,410 (31.5%) were women. Men were younger at diagnosis than women, with a mean age of 60.1 in men and 63.2 in women (p < 0.001), and had fewer risk factors at the time of diagnosis. Mean age at diagnosis had an overall increasing trend during the study period. Increasing trend was seen in body-mass index, hypertension prevalence, diabetes mellitus. All lipid profile components (total cholesterol, low-density lipoprotein cholesterol, triglycerides, and high-density lipoprotein cholesterol) decreased over time. Of particular interest, opium consumption was associated with 2.2 year earlier age of CAD diagnosis. CONCLUSION: The major results of this study (lower age of CAD diagnosis in men, lower age of diagnosis associated with most risk factors, and lower prevalence of serum lipids over time) were expected. A prominent finding of this study is confirming opium use was associated with a much younger age of CAD onset, even after adjusting for all other risk factors. In addition to recommendations for control of the traditional risk factors, spreading information about the potential adverse effect of opium use, which has only recently been associated with higher risk of CAD, may be necessary.

Clinical implications and indicators of mortality among patients hospitalized with concurrent COVID-19 and myocardial infarction.

OBJECTIVE: Acute ischemic cardiac events can complicate coronavirus disease 2019 (COVID-19). We report the in-hospital characteristics of patients with acute myocardial infarction and concomitant COVID-19. METHODS: This was a registry-based retrospective analysis of patients admitted with positive COVID-19 tests who suffered acute myocardial infarction either before or during hospitalization; from 1 March 2020 to 1 April 2020 in a tertiary cardiovascular center-Tehran Heart Center. We performed an exploratory analysis to compare the clinical characteristics of patients who died during hospitalization or were discharged alive. RESULTS: In March 2020, 57 patients who had acute myocardial infarction and a confirmed diagnosis of COVID-19 were included in the study. During hospitalization, 13 patients (22.8%) died after a mean hospital stay of 8.4 days. The deceased were older than the survivors. No significant association between mortality and sex or length of hospital stay was observed. Hypertensive individuals were more likely to have a fatal outcome. Previously receiving angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers did not show any association with mortality. Regarding the laboratory data during hospitalization, higher cardiac troponin T, neutrophil count, C-reactive protein, urea, and blood urea nitrogen/creatinine ratio were observed in the mortality group. The deceased had a lower lymphocyte count than the survivors. CONCLUSIONS: Markers of worsening renal function and immune system disturbance seem to be associated with mortality in concurrent acute myocardial infarction and COVID-19. Optimizing the management of acute coronary syndrome complicating COVID-19 requires addressing such potential contributors to mortality.

One-Year Outcome of Patients with Coronary Artery Ectasia Undergoing Percutaneous Coronary Intervention: Clinical Implications and Question Marks.

Background: Coronary artery ectasia (CAE) is a rare condition with unclear pathophysiology, optimal treatment, and prognosis. We aimed to determine the prognostic implications of CAE following coronary angioplasty. Methods: We conducted a retrospective cohort study on 385 patients, including 87 subjects with CAE, who underwent percutaneous coronary intervention (PCI). Major adverse cardiovascular events (MACE) were considered to consist of mortality, nonfatal myocardial infarction (MI), repeated revascularization, and stroke. Results: The mean age of the participants was 57.31±6.70 years. Multivariate regression analysis revealed that patients with diabetes, ST-segment-elevation MI at presentation, and high thrombus grades were more likely to have suboptimal post-PCI thrombolysis in myocardial infarction (TIMI) flow. However, CAE was not a predictor of a decreased TIMI flow (OR: 1.46, 95% CI: 0.78-8.32; P=0.391). The Cox-regression model showed that CAE, the body mass index, and a family history of MI were risk factors for MACE, while short lesion lengths (<20 vs >20 mm) had an inverse relationship. The adjusted hazard ratio (HR) for the prediction of MACE in the presence of CAE was 1.65 (95% CI: 1.08-4.78; P=0.391). All-cause mortality (HR: 1.69, 95% CI: 0.12-3.81; P=0.830) and nonfatal MI (HR: 1.03, 95% CI: 0.72-4.21; P=0.341) occurred similarly in the CAE and non-CAE groups. Conversely, CAE increased urgent repeat revascularization (HR: 2.40; 95% CI: 1.13-5.86; P=0.013). Conclusion: Although CAE had no substantial short-term prognostic effects on post-PCI TIMI flow, considerable concerns regarding adverse outcomes emerged during our extended follow-up. Stringent follow-ups of these patients should be underscored due to the high likelihood of urgent revascularization.

Correlation between the serum procalcitonin level and the extension and severity of coronary artery disease in patients with non-ST-segment elevation myocardial infarction.

Research has shown correlations between some, but not all, inflammatory mediators and coronary atherosclerosis burden. Conflicting results have been reported on the correlation between the serum procalcitonin (PCT) level and the severity and extension of coronary artery disease (CAD). We evaluated the correlation between PCT and the severity and extension of CAD in patients with non-ST-elevation myocardial infarction (NSTEMI). PATIENTS AND METHODS: In this prospective cross-sectional study, the serum PCT level was measured 48 h after hospital admission in 131 patients with a diagnosis of NSTEMI. All the patients underwent selective coronary angiography, and the severity and extension of their CAD was evaluated with the Gensini score. The study population was assigned to two groups on the basis of the median of the Gensini score: those with a score higher than the median and those with a score lower than the median. RESULTS: There was no statistically significant difference with regard to the serum PCT level between the two groups (P = 0.511). In the multivariable logistic regression analysis, after adjustment for the potential confounders, the serum PCT level was not a determinant of the Gensini score (P = 0.502). CONCLUSION: The second 24-h postadmission serum PCT level was not correlated with the severity and extension of CAD according to the Gensini score in our patients with NSTEMI.

Potential Role of Vitamin C Intracoronary Administration in Preventing Cardiac Injury After Primary Percutaneous Coronary Intervention in Patients with ST-Elevation Myocardial Infarction.

OBJECTIVE: The aim of the present study was to determine the effects of intravenous (IV) and intracoronary administration of Vitamin C on the incidence of periprocedural myocardial injury in patients undergoing primary percutaneous coronary intervention (PCI). METHODS: In this prospective, double-blind, randomized clinical trial, that was conducted in Tehran Heart Center, Iran, between October 2016 and March 2017, 252 patients undergoing primary PCI were enrolled to receive either 3 g of IV Vitamin C before PCI and 100 mg of intracoronary Vitamin C during PCI in addition to the routine treatment (n = 126) or just the routine treatment (n = 126). Cardiac biomarkers were measured before and then 6 and 12 h postprocedurally. We determined the occurrence of contrast-induced acute kidney injury (CI-AKI), according to the levels of serum creatinine, neutrophil gelatinase-associated lipocalin, and platelet activation biomarker (P-selectin) in a subset of 119 patients before and 6 h after PCI. FINDINGS: In the patients who received Vitamin C, the serum levels of troponin T after 12 h and creatine kinase-MB after 6 h were significantly lower than those in the placebo group (P = 0.003 andP = 0.00, respectively). CI-AKI occurred in 6 (4.7%) patients in the study group and 8 (6.3%) patients in the control group; there was no significant reduction in CI-AKI in the study group. In addition, the two groups were statically similar as regards the changes in the level of P-selectin. CONCLUSION: In primary PCI patients, the prophylactic use of IV and intracoronary Vitamin C can confer additional clinical benefits such as cardioprotection.

CHA2DS2-VASc Score as an Independent Predictor of Suboptimal Reperfusion and Short-Term Mortality after Primary PCI in Patients with Acute ST Segment Elevation Myocardial Infarction.

We aimed to demonstrate the clinical utility of CHA2DS2-VASc score in risk assessment of patients with STEMI regarding adverse clinical outcomes particularly no-reflow phenomenon. We designed a retrospective cohort study using the data of Tehran Heart Center registry for acute coronary syndrome. The study included 1331 consecutive patients with STEMI who underwent primary angioplasty. Patients were divided into two groups according to low and high CHA2DS2-VASc score. Angiographic results of reperfusion were inspected to evaluate the association of high CHA2DS2-VASc score and the likelihood of suboptimal TIMI flow. The secondary endpoint of the study was short-term in-hospital mortality of all cause. The present study confirmed that CHA2DS2-VASc model enables us to determine the risk of no-reflow and all-cause in-hospital mortality independently. Odds ratios were 1.59 (1.30⁻2.25) and 1.60 (1.17⁻2.19), respectively. Moreover, BMI, high thrombus grade, and cardiogenic shock were predictors of failed reperfusion (odds were 1.07 (1.01⁻1.35), 1.59 (1.28⁻1.76), and 8.65 (3.76⁻24.46), respectively). We showed that using a cut off value of ≥ two in CHA2DS2-VASc model provides a sensitivity of 69.7% and specificity of 64.4% for discrimination of increased mortality hazards. Area under the curve: 0.72 with 95% CI (0.62⁻0.81). Calculation of CHA2DS2-VASc score applied as a simple risk stratification tool before primary PCI affords great predictive power. Furthermore, incremental values are obtained by using both CHA2DS2-VASc and no-reflow regarding mortality risk assessment.

Effects of high dose atorvastatin before elective percutaneous coronary intervention on highly sensitive troponin T and one year major cardiovascular events; a randomized clinical trial.

INTRODUCTION: Some studies have demonstrated that post-PCI elevated cardiac enzymes are associated with worse outcomes. In this study, we aimed to determine if high-dose treatment with atorvastatin before planned elective PCI reduces PMI or MACE at 1-year median follow-up. MATERIAL AND METHODS: Eligible participants were randomly allocated to group A (80 mg atorvastatin 12 h and 40 mg 2 h before PCI) and group B (40 mg atorvastatin daily). Blood samples were obtained before and at 24 h after PCI to measure hsTnT. All patients were followed regarding MACE (combination of death, re-hospitalizations for ACS, and unplanned coronary revascularization) during one year after PCI. RESULTS: 207 patients randomly assigned to Group A (n = 97) or group B (n = 110). The rate of PMI was lower in group A (5.2%) compared to group B (10.9%); despite near to 50% lower rate of PMI in group A, binary logistic regression showed no significant association between atorvastatin recapture and PMI. The occurrence of MACE in 97 patients of group A was 11 (11.3%), higher than 11 (10%) cases of 110 patients in group B. Cox proportional hazards regression model shows no significant difference in MACE of study groups. CONCLUSION: Pretreatment of patients with stable angina who were planned to undergo an elective PCI with 120 mg of atorvastatin before the procedure confer them the same benefit in terms of PMI and MACE as 40 mg routine daily dosage of this statin does.

Single Long Stents versus Overlapping Multiple Stents in the Management of Very Long Coronary Lesions: Comparisons of Procedures and Clinical Outcomes.

Background: Different percutaneous coronary intervention (PCI) strategies, including the use of single long stents (SLSs) and overlapping multiple stents (OMSs), have been introduced to treat very long coronary lesions (VLCLs). The aim of this study was to compare procedural and long-term clinical outcomes between SLSs and OMSs in patients with VLCLs. Methods: In this historical cohort study, 1709 patients who underwent PCI with the new generation of drug-eluting stents (length ≥38 mm) were stratified into the SLS [PROMUS /Resolute/XIENCE (PRX), (=38 mm), n=1121 (65.59%) and BioMime, (≥40 mm), n=124 (7.26%)] and OMS [(59.43±10.80 mm), n=464 (27.2%)] groups and followed up for 440.93±361.32 days. The study endpoints comprised immediate post-PCI outcomes, major adverse cardiovascular events (MACE), the patient-oriented composite endpoint (POCE), and the device-oriented composite endpoint (DOCE) at the long-term follow-up. Results: The mean age of the patients was 59.28±10.60 years, and 69.6% of them were male. Flow grade 3 (P=0.296) and residual stenosis (P=0.533) were statistically similar between all the groups. A lower level of post-PCI troponin was observed in the BioMime group [14.52 (IQR25%-75%:10.44-22.42) ng/L; P=0.031] than in the PRX and OMS groups [18.63 (IQR25%-75%:10.51-34.02) ng/L and 18.96 (IQR25%-75%:11.17-35.34) ng/L; respectively]. Similarly, the PRX and BioMime groups received lower amounts of the contrast agent [206.29±49.15 mL and 208.06±55.23 mL; respectively] than did the OMS group [265.50±74.69 mL; P<0.001]. There were no statistically significant differences in the incidence of MACE [81 (7.2%), 7 (5.6%), and 28 (6.0%); P=0.603], the POCE [141 (12.6%), 13 (10.5%), and 54 (11.6%); P=0.731], and the DOCE [51 (4.5%), 4 (3.2%), and 21 (4.5%); P=0.791] between the PRX, BioMime, and OMS groups, respectively. Conclusion: In the treatment of VLCLs, the SLS and OMSs appear to have similar clinical outcomes. BioMime ultra-long stents may have comparable results to PRX coronary stents.

Comparing Serum Level of Vitamin D3 in Patients With Isolated Coronary Artery Ectasia and Normal Coronary Artery Individuals.

BACKGROUND: Coronary artery ectasia (CAE) is identified as dilation of one or more segments of coronary arteries that reaches 1.5 times or more, compared with near segments that are normal. Several etiologies like atherosclerosis, autoimmune diseases and congenital anomalies have been proposed for this condition. Vitamin D deficiency activates the renin-angiotensin-aldosterone system, which affects the cardiovascular system. For these reasons, we investigated the serum level of vitamin D in patients with CAE compared with individuals with normal coronary arteries. METHODS: The study group included 30 patients (20 males and 10 females, mean age: 57 ± 9 years) with isolated CAE without any stenotic lesions, and the control group consisted of 60 age/gender matched subjects who had normal coronary angiograms (CAG) (40 males and 20 females, mean age: 57 ± 8 years). All participants underwent CAG at Tehran Heart Center between December 2015 and March 2016. Along with routine lab tests, vitamin D, serum albumin, calcium, phosphorus and alkaline phosphatase levels were analyzed and the unadjusted and adjusted effects of vitamin D on CAE were evaluated using logistic regression model. RESULTS: The median vitamin D level of the patients with CAE was lower than that of the control group (6.5 [3.0, 18.8] ng/mL vs. 17.7 [8.9, 27.1] ng/mL; P = 0.002). The logistic regression model showed that vitamin D deficiency was a predictor for the presence of CEA (P = 0.013). After adjustment for confounding variables, this association remained significant (P = 0.025). CONCLUSION: An association between CAE and vitamin D deficiency was found in our study.

Predictors of Long-term Major Adverse Cardiac Events Following Percutaneous Coronary Intervention in the Elderly.

BACKGROUND: We aimed to recognize the predictors of long-term major adverse cardiac events (MACE) in the elderly candidates for elective percutaneous coronary intervention (PCI) at our center. METHODS: In this retrospective cohort study, we reviewed the data of the elderly (age ≥65 years) candidates for elective PCI who met our study criteria, at Tehran heart center between 2004 and 2013. Demographic, anthropometric, clinical, angiographic, procedural and follow-up data of the enrolled patients were retrieved from the angiography/PCI databank of our center. The study characteristics of the patients with or without MACE were compared in a univariable Cox-regression analysis. A multivariable Cox-regression model was applied using variables selected from the univariable model to determine the predictors of MACE. RESULTS: We reviewed the data of 2772 patients (mean age=70.8±4.7 years, male sex=1726 patients [62.3%]) from which 393 patients (14.4%) developed MACE. In the multivariable regression model, female sex was a protective factor for MACE (hazard ratio [HR]=0.701; P=0.001), while presence of diabetes mellitus (HR=1.333; P=0.007), family history of coronary artery disease (CAD) (HR=1.489; P=0.003) and plain balloon angioplasty (HR=1.810; P=0.010) were independent risk factors for MACE. CONCLUSION: PCI is a safe and effective method of revascularization in the elderly patients, and some clinical and procedural factors can predict MACE in this group of patients.

Predictors of major adverse cardiac events following elective stenting of large coronary arteries.

OBJECTIVE: Diameter of the affected coronary artery is an important predictor of restenosis and need for revascularization. In the present study, we investigated the frequency and potential risk factors for major adverse cardiac events following elective percutaneous coronary intervention (PCI) and stenting of large coronary arteries. METHODS: We reviewed the data of elective candidates of PCI on a large coronary artery who presented to our center. Demographic, clinical, angiographic and follow-up data of the eligible patients were retrieved from our databank. The study characteristics were then compared between the patients with and without MACE in order to find out the probable risk factors for MACE in patients with large stent diameter. RESULTS: Data of 3043 patients who underwent single vessel elective PCI with a stent diameter of ≥3.5mm was reviewed. During a median follow up period of 14 months, 64 (2.1%) patients had MACE. TVR was the most common type of MACE that was observed in 29 patients, while 5 patients had cardiac death. Higher serum levels of creatinine, history of cerebrovascular accident (CVA), and use of a drug eluting stent (DES) were significantly associated with MACE. In the multivariate model, history of CVA (odds ratio=5.23, P=0.030) and use of DES (odds ratio=0.048, P=0.011) were the independent predictors of MACE in patients underwent large coronary artery stenting. CONCLUSION: This study showed that prior CVA and the use of BMS were the potential risk factors for MACE in patients who were stented on their large coronary arteries.

Protection from Reperfusion Injury with Intracoronary N-Acetylcysteine in Patients with STEMI Undergoing Primary Percutaneous Coronary Intervention in a Cardiac Tertiary Center.

BACKGROUND: Evidence suggests that oxidative stress plays a principal role in myocardial damage following ischemia/reperfusion events. Recent studies have shown that the antioxidant properties of N-acetylcysteine (NAC) may have cardioprotective effects in high doses, but-to the best of our knowledge-few studies have assessed this. OBJECTIVES: Our objective was to investigate the impact of high-dose NAC on ischemia/reperfusion injury. METHODS: We conducted a randomized double-blind placebo-controlled trial in which 100 consecutive patients with ST-elevation myocardial infarction undergoing percutaneous coronary intervention (PCI) were randomly assigned to the case group (high-dose NAC 100 mg/kg bolus followed by intracoronary NAC 480 mg during PCI then intravenous NAC 10 mg/kg for 12 h) or the control group (5% dextrose). We measured differences in peak creatine kinase-myocardial band (CK-MB) concentration, highly sensitive troponin T (hs-TnT), thrombolysis in myocardial infarction (TIMI) flow, myocardial blush grade (MBG), and corrected thrombolysis in myocardial infarction frame count (cTFC). RESULTS: The peak CK-MB level was comparable between the two groups (P = 0.327), but patients receiving high-dose NAC demonstrated a significantly larger reduction in hs-TnT (P = 0.02). In total, 94% of the NAC group achieved TIMI flow grade 3 versus 80% of the control group (P = 0.03). No significant differences were observed between the two groups in terms of changes in the cTFC and MBG. CONCLUSIONS: In this study, NAC improved myocardial reperfusion markers and coronary blood flow, as revealed by differences in peak hs-TnT and TIMI flow grade 3 levels, respectively. Further studies with large samples are warranted to elucidate the role of NAC in this population. ClinicalTrials.gov identifier: NCT01741207, and the Iranian Registry of Clinical Trials (IRCT; http://irct.ir ) registration number: IRCT201301048698N8.

Effect of High-Dose Allopurinol Pretreatment on Cardiac Biomarkers of Patients Undergoing Elective Percutaneous Coronary Intervention: A Randomized Clinical Trial.

BACKGROUND: Increased accumulation of reactive oxygen species contributes to pathophysiologic states such as endothelial dysfunction, metabolic and functional impairment, inflammatory activation, and other features of cardiovascular pathophysiology. Allopurinol acts as a xanthine oxidase inhibitor that reduces the amount of free radicals after reactive oxygen species generation. METHODS AND RESULTS: In this placebo-controlled randomized clinical trial, all patients admitted with coronary artery disease who are candidates for elective percutaneous coronary intervention (PCI) were included. The 254 patients were randomly divided into 2 groups. Blood samples for cardiac biomarkers (creatine kinase [CK]-MB and troponin T [cTnT]) were collected from all patients after admission (the day before PCI), and also 8 and 16 hours after intervention. In group 1 (133 patients), 600 mg allopurinol was orally administered on the day before PCI, and another same dose on the day of PCI, and the elective PCI was performed. In group 2 (121 patients), elective PCI was performed without pretreatment with allopurinol. In an unadjusted model, the serum levels of both CK-MB and cTnT, 16 hours after PCI were higher in the placebo group as compared with the allopurinol group, although it was statistically insignificant. We compared the maximum levels of CK-MB and cTnT (8 or 16 hours after PCI) and their maximum changes in both groups. After adjustment for confounders, use of allopurinol did not have any statistically significant association with the rise of cardiac-spec-fic enzymes. CONCLUSIONS: Allopurinol could not be effective significantly, in patients undergoing elective PCI, to decrease cardiac-specific enzymes, and seems not to be of use before PCI.

Potential Role of Allopurinol in Preventing Contrast-Induced Nephropathy in Patients Undergoing Percutaneous Coronary Intervention: A Randomized Placebo-Controlled Trial.

BACKGROUND: Contrast-induced nephropathy (CIN) is a major drawback in percutaneous coronary intervention (PCI). Significant uricosuria has been reported following contrast exposure. Allopurinol-a xanthine oxidase inhibitor-has been suggested to prevent the formation of oxygen-free radicals, which may contribute to CIN. The aim of the present study was to evaluate the possible efficacy of allopurinol in preventing CIN. METHODS: In this double-blind placebo-controlled trial, patients with an estimated glomerular filtration rate ≥60 mL/min who were admitted for elective PCI, were randomized to receive either allopurinol 600 mg or a placebo administered 24 h before the procedure, and again immediately before the procedure. Blood samples were drawn at 24 h before and 24 h after contrast exposure to measure serum creatinine (SCr), uric acid, and serum cystatin-c. RESULTS: The baseline characteristics were almost similar between the placebo and allopurinol groups. The overall change in SCr and the rate of CIN, which is defined as ≥25% increase in serum cystatin-c relative to baseline, failed to show a significant difference between the two groups. When adjusted on the baseline cystatin-c, SCr, sex, and positive family history, the difference in the overall increase in serum cystatin-c was statistically significantly lower in the allopurinol group. CONCLUSIONS: Allopurinol administration in patients undergoing PCI failed to show efficacy in preventing CIN. Nevertheless, this effect should be further evaluated in the patient population with chronic kidney disease.