Contribution of genetic variants in the development of familial premature coronary artery disease in a cohort of cardiac patients.

Coronary artery disease (CAD), the most prevalent cardiovascular disease, is the leading cause of death worldwide. Heritable factors play a significant role in the pathogenesis of CAD. It has been proposed that approximately one-third of patients with CAD have a positive family history, and individuals with such history are at ~1.5-fold increased risk of CAD in their lifespans. Accordingly, the long-recognized familial clustering of CAD is a strong risk factor for this disease. Our study aimed to identify candidate genetic variants contributing to CAD by studying a cohort of 60 large Iranian families with at least two members in different generations afflicted with premature CAD (PCAD), defined as established disease at ≤45 years in men and ≤55 years in women. Exome sequencing was performed for a subset of the affected individuals, followed by prioritization and Sanger sequencing of candidate variants in all available family members. Subsequently, apparently healthy carriers of potential risk variants underwent coronary computed tomography angiography (CCTA), followed by co-segregation analysis of the combined data. Putative causal variants were identified in seven genes, ABCG8, CD36, CYP27A1, PIK3C2G, RASSF9, RYR2, and ZFYVE21, co-segregating with familial PCAD in seven unrelated families. Among these, PIK3C2G, RASSF9, and ZFYVE21 are novel candidate CAD susceptibility genes. Our findings indicate that rare variants in genes identified in this study are involved in CAD development.

Sex-based association between high-density lipoprotein cholesterol and adverse outcomes after coronary artery bypass grafting.

BACKGROUND: High-density lipoprotein cholesterol (HDL-C) is shown to be an independent protective factor against coronary artery diseases (CAD). Yet there are limited studies focusing on the association between HDL-C and coronary artery bypass graft (CABG) surgery outcomes. HYPOTHESIS: Low levels of HDL-C are associated with higher incidence of adverse outcomes in patients undergoing CABG. METHODS: This registry-based study included 17,772 patients who underwent elective isolated CABG between 2007 and 2017. Patients were classified into low and desirable HDL-C groups based on their serum HDL-C levels at admission and were followed for one-year post-surgery. The study population included 13,321 patients with low HDL-C and 4,451 with desirable HDL-C. proportional hazard Cox models were performed to evaluate the association between HDL-C levels and incidence of mortality as well as major adverse cardiovascular and cerebrovascular events (MACCE), while adjusting for potential confounders. Moreover, participants were stratified based on sex and the association was also investigated in each subgroup separately. RESULTS: No significant difference was found between the groups regarding incidence of both mortality and MACCE, after adjusting with Inverse Probability Weighting (IPW) [HR (95%CI): 0.84 (0.46-1.53), p-value:0.575 and HR (95% CI): 0.91 (0.56-1.50), p-value:0.733, respectively]. According to the sex-based subgroup analysis, no significant association was observed after adjustment with IPW analysis. However, as we examined the association between the interaction of HDL-C levels, sex and cardiovascular outcomes, we found a significant association (HR;1.19 (95%CI: 1.04-1.45); p = 0.030). CONCLUSION: HDL-C level was not associated with either mortality or MACCE during one year after CABG procedure. Sex-based analysis showed that in males, HDL-C is significantly more protective against these outcomes, compared to females. Further studies are necessary to elucidate the exact mechanisms mediating such association.

Heart surgery over two decades: what we have learned about results and changing risks.

OBJECTIVES: Using the cardiac surgery database is of high importance in referral centers and can lead to a better quality of care for patients. Tehran Heart Center (THC) is a cardiovascular referral center that was inaugurated in 2001. In this report, we aimed to present the third report of trends in patients' cardiovascular risk factors and surgical procedures from 2002 to 2021 that have been gathered for all THC patients. METHODS: This serial cross-sectional study was conducted at Tehran Heart Center from 2002 to 2021. All patients undergoing cardiac surgeries were eligible to enter the study (N = 63,974). Those with miscellaneous types of surgeries were excluded (N = 9556). The distribution of cardiac surgeries (including isolated coronary artery bypass graft (CABG), isolated valve, and CABG + valve surgeries) and their respective in-hospital mortality were recorded. Furthermore, 20-year trends in the prevalence of various cardiovascular risk factors (CVRFs) among the following groups were evaluated: a) isolated CABG, b) aortic valve replacement/repair for aortic stenosis (AS/AVR/r), and c) isolated other valve surgeries (IVS). RESULTS: A total of 54,418 patients (male: 70.7%, age: 62.7 ± 10.8 years) comprised the final study population, with 84.5% prevalence of isolated CABG. Overall, the AS/AVR/r group was in between the CABG and IVS groups concerning CVRFs distribution. Excluding some exceptions for the AS/AVR/r group (in which the small sample size (N = 909) precluded observing a clear trend), all studied CVRFs demonstrated an overall rising trend from 2002 to 2021 in all three groups. Regarding in-hospital mortality, the highest rate was recorded as 4.0% in 2020, while the lowest rate was 2.0% in 2001. CONCLUSIONS: Isolated CABG remained the most frequent procedure in THC. Notable, increasing trends in CVRFs were observed during this 20-year period and across various types of cardiac surgeries, which highlights the clinical and policy-making implications of our findings.

Epidemiology of substance and opium use among adult residents of Tehran; a comprehensive report from Tehran cohort study (TeCS).

BACKGROUND: The prevalence and burden of substance and opium use have increased worldwide over the past decades. In light of rapid population changes in Tehran, we aimed to evaluate the prevalence of opium and other substance use among adult residents in Tehran, Iran. METHOD: From March 2016 to March 2019, we utilized data from 8 296 participants in the Tehran Cohort Study recruitment phase (TeCS). We calculated the age-sex-weighted prevalence of substance use and the geographic distribution of substance use in Tehran. We also used logistic regression analysis to determine possible determinants of opium use. RESULT: We analyzed data from 8 259 eligible participants with complete substance use data and the average age of participants was 53.7 ± 12.75 years. The prevalence of substance use was 5.6% (95% confidence interval [CI]: 4.6- 7.1%). Substance use was more common in males than females (Prevalence: 10.5% [95% CI: 8.6- 12.6%] vs. 0.5% [95% CI: 0.2- 1.2%], respectively). The age-sex weighted prevalence of substance use was 5.4% (95% CI: 4.6-7.1%). Moreover, opium was the most frequently used substance by 95.8% of substance users. Additionally, we found that male gender (Odds ratio [OR]: 12.1, P < 0.001), alcohol intake (OR: 1.3, P = 0.016), and smoking (OR: 8.5, P < 0.001) were independently associated with opium use. CONCLUSIONS: We found that the prevalence of substance use in Tehran was 5.6%, and opium was the most frequently used substance. In addition, male gender, lower levels of education, alcohol, and tobacco consumption are the main risk factors for substance use in Tehran. Healthcare providers and policymakers can utilize our results to implement preventive strategies to minimize substance use in Tehran.

Prevalence of insufficient physical activity among adult residents of Tehran: a cross-sectional report from Tehran Cohort Study (TeCS).

BACKGROUND: Insufficient physical activity (PA) is a major risk factor for non-communicable diseases (NCDs) and one of the leading causes of premature mortality worldwide. This study examined the prevalence and independent determinants of insufficient PA among adults resident of Tehran utilizing Tehran Cohort Study Data (TeCS). METHOD: We used the recruitment phase data from the TeCS with complete data on PA. PA was assessed through a Likert-scaled question and categorized into three groups. Utilizing data from the 2016 national census, the age- and sex-weighted prevalence of insufficient PA in Tehran was determined. The adjusted logistic regression model is used to neutralize influencing factors and determine the factors associated with insufficient PA. RESULT: The weighted prevalence of insufficient PA was 16.9% among the 8213 adult citizens of Tehran, with a greater prevalence among females (19.0% vs. 14.8% among males). Additionally, older age groups, unemployed, housewives, and illiterate educated participants displayed a much higher prevalence of insufficient PA (p < 0.001). Moreover, Tehran's central and southern districts had higher rates of insufficient PA. Concerning the adjusted regression model, older age (Odds ratio [OR]: 4.26, 95% confidence interval [95% CI]: 3.24-5.60, p < 0.001), a lower education level (p < 0.001), unemployment (OR: 1.80, 95% CI: 1.28-2.55, p = 0.001), being a housewife (OR: 1.44, 95% CI: 1.15-1.80, p = 0.002), higher body mass index (BMI) (OR for BMI > 30: 1.85, 95% CI: 1.56-2.18, p < 0.001), opium consumption (OR: 1.92, 95% CI: 1.46-2.52, p < 0.001), diabetes mellitus (OR: 1.25, 95% CI: 1.06-1.48, p = 0.008), hypertension (OR: 1.29, 95% CI: 1.11-1.50, p = 0.001), and coronary artery diseases (OR: 1.30, 95% CI: 1.05-1.61, p = 0.018), were significantly associated with insufficient PA. CONCLUSIONS: The identified associated factors serve as a valuable guide for policymakers in developing tailored intervention strategies to address the needs of high-risk populations, particularly among older adults and females.

7-year outcomes in diabetic patients after coronary artery bypass graft in a developing country.

BACKGROUND: Revascularization in diabetic patients with coronary artery disease remains a challenge in cardiology practice. Although clinical trials have reported the mid-term superiority of coronary artery bypass grafting (CABG) surgery over percutaneous coronary intervention in these patients, little is known about the long-term outcomes of CABG in diabetic patients compared to non-diabetics, particularly in developing countries. METHODS: Between 2007 and 2016, we recruited all patients who underwent isolated CABG in a tertiary care cardiovascular center in a developing country. The patients were followed at 3-6 months and 12 months after surgery, and then annually. The study endpoints were 7-year all-cause mortality and major adverse cardiac and cerebrovascular events (MACCE). RESULTS: Of 23,873 patients (17,529 males, mean age 65.67 years) who underwent CABG, 9227 (38.65%) patients were diagnosed with diabetes. After adjustment for potential confounders, patients with diabetes experienced a 31% increase in MACCE seven years after surgery compared to the non-diabetic patients (HR = 1.31, 95% CI: 1.25-1.38, P-value < 0.0001). Meanwhile, diabetes contributes to a 52% increase in the risk of all-cause mortality after CABG (HR = 1.52, 95% CI: 1.42-1.61, P-value < 0.0001). CONCLUSIONS: Our study showed a higher risk of all-cause mortality and MACCE at seven years in diabetic patients undergoing isolated CABG. The outcomes in the studied center in a developing country were comparable to western centers. The high incidence of adverse outcomes in the long term in diabetic patients implies that not only short-term but long-term measures should be taken to improve the CABG outcomes in this challenging patient population.

Brain MRI and EEG overemployment in patients with vasovagal syncope: results from a tertiary syncope unit.

BACKGROUND: The diagnosis of vasovagal syncope (VVS) is mainly based on history-taking and physical examination. However, brain Magnetic Resonance Imaging (MRI) and Electroencephalogram (EEG) are commonly used in the diagnostic course of VVS, despite not being indicated in the guidelines. This study aims to find the possible associated factors with the administration of brain MRI and EEG in patients with VVS. METHODS: Patients with a diagnosis of VVS from 2017 to 2022 were included. Several demographic and syncope features were recorded. The association of these was assessed with undergoing MRI, EEG, and either MRI or EEG. Univariate and multivariable logistic regression models were also used to calculate odds ratios (OR) and 95% confidence intervals (CI). RESULTS: A total of 1882 patients with VVS were analyzed, among which 810 underwent MRI (43.04%), 985 underwent EEG (52.34%), and 1166 underwent MRI or EEG (61.96%). Head trauma (OR 1.38, 95% CI 1.06 to 1.80), previous neurologist visit (OR 6.28, 95% CI 4.24 to 9.64), and gaze disturbance during syncope (OR 1.75, 95% CI 1.13 to 2.78) were all positively associated to the performance of brain MRI/EEG. Similar results were found for urinary incontinence (OR 2.415, 95% CI 1.494 to 4.055), amnesia (OR 1.421, 95% CI 1.053 to 1.930), headache after syncope (OR 1.321, 95% CI 1.046 to 1.672), and tonic-clonic movements in head-up tilt table test (OR 1.501, 95% CI 1.087 to 2.093). However, male sex (OR 0.655, 95% CI 0.535 to 0.800) and chest pain before syncope (OR 0.628, 95% CI 0.459 to 0.860) had significant negative associations with performing brain MRI/EEG. CONCLUSION: Based on our findings, performing MRI or EEG was common among VVS patients while it is not indicated in the majority of cases. This should be taken into consideration to prevent inappropriate MRI/EEG when there is a typical history compatible with VVS.

Age and gender differences of basic electrocardiographic values and abnormalities in the general adult population; Tehran Cohort Study.

BACKGROUND: Although several studies are available regarding baseline Electrocardiographic (ECG) parameters and major and minor ECG abnormalities, there is considerable controversy regarding their age and gender differences in the literature. METHODS: Data from 7630 adults aged ≥ 35 from the Tehran Cohort Study registered between March 2016 and March 2019 were collected. Basic ECG parameters values and abnormalities related to arrhythmia, defined according to the American Heart Association definitions, were analyzed and compared between genders and four distinct age groups. The odds ratio of having any major ECG abnormality between men and women, stratified by age, was calculated. RESULTS: The average age was 53.6 (± 12.66), and women made up 54.2% (n = 4132) of subjects. The average heart rate (HR) was higher among women(p < 0.0001), while the average values of QRS duration, P wave duration, and RR intervals were higher among men(p < 0.0001). Major ECG abnormalities were observed in 2.9% of the study population (right bundle branch block, left bundle branch block, and Atrial Fibrillation were the most common) and were more prevalent among men compared to women but without statistical significance (3.1% vs. 2.7% p = 0.188). Moreover, minor abnormalities were observed in 25.9% of the study population and again were more prevalent among men (36.4% vs. 17% p < 0.001). The prevalence of major ECG abnormalities was significantly higher in participants older than 65. CONCLUSION: Major and minor ECG abnormalities were roughly more prevalent in male subjects. In both genders, the odds of having major ECG abnormalities surge with an increase in age.

Clinical outcomes of subcutaneous implantable cardiac defibrillator implantation - Iran SICD registry.

BACKGROUND: The subcutaneous implantable-defibrillator (S-ICD) is a relatively new alternative to the transvenous ICD system to minimize intravascular lead-related complications. This paper presents outcome of SICD implantation in patients enrolled in Iran S-ICD registry. METHODS: Between October 2015 and June 2022, this prospective multicenter national registry included 223 patients with a standard indication for an ICD, who neither required bradycardia pacing nor needed cardiac resynchronization to evaluate the early post-implant complications and long-term follow-up results of the S-ICD system. RESULTS: The mean age of the patients was 45 ± 17 years. The majority (79.4%) were male. Ischemic cardiomyopathy (39.5%) was the most common underlying disorder among patients selected for S-ICD implant. Most study patients (68.6%) had ICD for primary prevention of sudden cardiac death. Seven patients (3.1%) were found to have suboptimal lead positions. Six patients (2.7%) developed a pocket hematoma; all were managed medically. During a mean follow-up of 2 years, the appropriate therapy was recorded in 13% of the patients and inappropriate ICD intervention mainly due to supraventricular tachycardia in 8.9%. Pocket infection was observed in four patients (1.8%) and five patients (2.2%) died mainly due to heart failure. CONCLUSION: S-ICDs were effective at detecting and treating both induced and spontaneous ventricular arrhythmias. Major clinical complications were rare.

Epidemiology and prevalence of tobacco use in Tehran; a report from the recruitment phase of Tehran cohort study.

INTRODUCTION: Tobacco use is a major health concern worldwide, especially in low/middle-income countries. We aimed to assess the prevalence of cigarette smoking, waterpipe, and pipe use in Tehran, Iran. METHODS: We used data from 8272 participants of the Tehran Cohort Study recruitment phase. Tobacco use was defined as a positive answer to using cigarettes, waterpipes, or pipes. Participants who did not report tobacco use during the interview but had a previous smoking history were categorized as former users. Age- and sex-weighted prevalence rates were calculated based on the national census data, and characteristics of current and former tobacco users were analyzed. RESULTS: Age- and sex-weighted prevalence of current tobacco users, cigarette smokers, waterpipe, and pipe users in Tehran was 19.8%, 14.9%, 6.1%, and 0.5%, respectively. Current tobacco use was higher in younger individuals (35-45 years: 23.4% vs. ≥ 75 years: 10.4%, P < 0.001) and men compared to women (32.9% vs. 7.7% P < 0.001). The prevalence of tobacco use increased with more years of education (> 12 years: 19.3% vs. illiterate: 9.7%, P < 0.001), lower body mass index (< 20 kg/m2: 31.3% vs. ≥ 35 kg/m2: 13.8%, P < 0.001), higher physical activity (high: 23.0% vs. low: 16.4%, P < 0.001), opium (user: 66.6% vs. non-user: 16.5%, P < 0.001), and alcohol use (drinker: 57.5% vs. non-drinker: 15.4%, P < 0.001). Waterpipe users were younger (46.1 vs. 53.2 years) and had a narrower gender gap in prevalence than cigarette smokers (male/female ratio in waterpipe users: 2.39 vs. cigarette smokers: 5.47). Opium (OR = 5.557, P < 0.001) and alcohol consumption (OR = 4.737, P < 0.001) were strongly associated with tobacco use. Hypertension was negatively associated with tobacco use (OR = 0.774, P = 0.005). CONCLUSION: The concerning prevalence of tobacco use in Tehran and its large gender gap for cigarette and waterpipe use warrant tailored preventive policies.

Compression stockings for treating vasovagal syncope (COMFORTS-II) trial: Rationale and design of a triple-blind, multi-center, randomized controlled trial.

BACKGROUND: Reduced venous return is an important trigger of vasovagal syncope (VVS). Elastic compression stockings (ECS) can modify venous return and be of therapeutic interest; however, evidence for ECS efficacy in VVS is scarce. This randomized controlled trial was designed to address the issue. METHODS: COMFORTS-II is a multicenter, triple-blind, parallel design, randomized controlled trial aimed to assess the efficacy of ECS in preventing VVS recurrences. Using central online randomization, 268 participants will be allocated to 2 arms (1:1 ratio), wearing intervention ECS (25-30 mm Hg pressure) or sham ECS (≤10 mm Hg pressure). All participants will receive standard VVS treatment in the form of education, and lifestyle modification recommendations (drinking 2-3 l/d of fluids and consuming 10 g/d-roughly half a tablespoon-of table salt). Adherence to ECS treatment will be evaluated through diary sheets, and compared between study arms. Follow-up continues for 1 year, and is conducted via a 24/7 phone line available to patients and trimonthly visits. The co-primary outcomes are proportion of participants with any syncopal recurrence and time to first syncopal episode. Secondary outcomes include frequency of VVS spells, time intervals between recurrences, and incidence of any patient-reported adverse effects. CONCLUSION: To the best of our knowledge, COMFORTS-II is the first clinical trial to assess ECS efficacy among patients with VVS, addressing an important gap in evidence for VVS treatments.

Implementation of supervised physical training to reduce vasovagal syncope recurrence: A randomized controlled trial.

INTRODUCTION: Physical techniques used for the prevention of vasovagal syncope have limited evidence for efficacy. We aimed to evaluate multimodal supervised physical training as a treatment approach. METHODS: In this 1:1 randomized trial, patients with ≥2 episodes of clinically diagnosed vasovagal syncope were included. On top of standard care, the intervention arm performed supervised tilt training and aerobic exercise in six sessions at a cardiac rehabilitation center (three sessions during the first month, and then at 3-month intervals), plus home tilt training. The control arm received standard care with a similar protocol of home tilt training. The primary outcome was time to first syncopal recurrence during 1 year of follow-up. RESULTS: Fifty participants were randomized (mean age: 34.5 ± 14.8 years; 64% female). The rate of syncopal recurrence was 28% and 64% within the intervention and control arms, respectively, with significantly higher syncope-free survival at 1 year in the intervention arm (Log-rank p = .003). The frequency of recurrent syncopal events was significantly lower with physical training (p = .017). Participants in the intervention arm reported significantly higher adherence to the home tilt training program (80% vs. 52%; p = .037). CONCLUSION: Among patients with recurrent vasovagal syncope, a supervised program of tilt training and aerobic exercise reduced syncopal recurrence. Future trials are warranted to further investigate multimodal supervised physical techniques as a therapeutic approach in treating vasovagal syncope.

Prevalence, awareness, treatment, and control of type 2 diabetes mellitus among the adult residents of tehran: Tehran Cohort Study.

BACKGROUND: The prevalence of type 2 diabetes mellitus has increased in the past decades. We investigated the prevalence of diabetes and its awareness, treatment, and control among adult residents of Tehran. METHODS: We used the recruitment phase data of the Tehran Cohort study, enrolling a random sample of adult residents of Tehran aged ≥35 years. Diabetes was defined as self-report, current use of glucose-lowering medications, and/or fasting plasma glucose (FPG) ≥126mg/dl. Impaired fasting glucose (IFG) was defined as an FPG of 100-125mg/dl. Awareness was defined as diabetes self-report, treatment as receiving glucose-lowering medications, and glycemic control as FPG <126mg/dl. The age- and sex-weighted estimates were calculated using the 2016 national census. Logistic regression models were used to determine the factors associated with diabetes awareness, treatment, and control. RESULTS: A total of 8151 participants were included. Age- and sex-weighted prevalence of diabetes mellitus and IFG were 16.7% (95% CI: 15.1-18.4) and 25.1% (95% CI: 23.1-27.1), respectively. Diabetes was more prevalent in the eastern and central districts of Tehran. Advanced age (OR per 1-year increase: 1.026, 95% CI: 1.021-1.030), male sex (OR: 1.716, 95% CI: 1.543-1.909), higher BMI levels (OR for BMI ≥35 vs. <20 kg/m2: 4.852, 95% CI: 3.365-6.998), pre-existing hypertension (OR: 1.552, 95% CI: 1.378-1.747), dyslipidemia (OR: 1.692, 95% CI: 1.521-1.883), and chronic kidney disease (OR: 1.650, 95% CI: 1.019-2.673) were associated with an increased odds of diabetes mellitus. On the contrary, diabetes mellitus was less likely in current tobacco (OR: 0.872, 95% CI: 0.765-0.994) and alcohol users (OR: 0.836, 95% CI: 0.703-0.994) compared to non-users. Among diabetic individuals, 82.8% were aware of their condition, 71.9% received treatment, and 31.7% of treated patients had adequate glycemic control. Advanced age and pre-existing comorbidities, including hypertension and dyslipidemia, were associated with higher diabetes awareness and treatment. Furthermore, advanced age, higher levels of education, and female sex were determinants of better glycemic control among treated diabetic participants. CONCLUSION: There is a high prevalence of diabetes and IFG among adult residents of Tehran. Additionally, more than two-thirds of treated diabetics living in Tehran remain uncontrolled.

Off-pump versus on-pump coronary artery bypass graft surgery outcomes in patients with severe left ventricle dysfunction: inverse probability weighted study.

OBJECTIVE: In this study we aimed to compare on-pump and off-pump coronary artery bypass grafting (CABG) outcomes in patients presented with low left ventricular ejection fraction (EF) as a high-risk group of patients. METHODS: In this registry-based study from 2014 and 2016, all patients with severe left ventricular dysfunction (EF less than 35%) were included and followed until 2020. The median follow-up period was 47.83 [38.41, 55.19] months. Off pump CABG (OPCABG) was compared with on-pump CABG (ONCABG) in terms of mid-term non-fatal cardiovascular events (CVEs) and all-cause mortality. Propensity score method (with inverse probability weighting technique) was used to compare these two groups. RESULTS: From 14,237 patients who underwent isolated CABG, 2055 patients with EF ≤ 35% were included; 1705 in ONCABG and 350 patients in OPCABG groups. Although OPCABG was associated with lower risk of 30-days mortality (Odds Ratio [OR]: 0.021; Confidence Interval [CI] 95% [0.01, 0.05], P < 0.001); there was no significant difference between OPCABG and ONCABG in term of mid-term mortality and non-fatal CVEs ((Hazard ratio [HR]: 0.822; 95%CI [0.605, 1.112], p = 0.208) and (HR: 1.246; 95%CI [0.805, 1.929], p = 0.324), respectively). Patients with more than three traditional coronary artery disease risk factors, had more favorable outcomes (in terms of mid-term mortality) if underwent OPCABG (HR: 0.420; 95%CI [0.178, 0.992], p = 0.048). CONCLUSION: OPCABG was associated with lower risk of 30-days mortality; however, mid-term outcomes were comparable in both OPCABG and ONCABG techniques.

Utility of the CHA2DS2-VASc Score in Prediction of Postoperative Atrial Fibrillation After Coronary Artery Bypass Graft Surgery.

OBJECTIVE: The authors aimed to investigate the role of CHA2DS2-VASc score and its components in prediction of postoperative atrial fibrillation (POAF) after isolated coronary artery bypass graft (CABG) surgery. DESIGN: Retrospective cohort. SETTING: Single-center university-affiliated tertiary cardiac center. PARTICIPANTS: A total of 2,981 consecutive patients who underwent isolated CABG between 2010 and 2012 were included. INTERVENTIONS: All patients underwent isolated CABG and were followed until discharge or in-hospital death. The primary outcome was the development of new-onset POAF during the hospital course. MEASUREMENTS AND MAIN RESULTS: During hospitalization, continuous electrocardiogram monitoring was used to detect POAF episodes. New-onset POAF developed in 15.8% of patients following isolated CABG. Patients with POAF had significantly higher CHA2DS2-VASc scores than those without POAF (2.66 ± 1.51 v 2.12 ± 1.36, p < 0.001). After adjustment for potential confounders, CHA2DS2-VASc score was significantly associated with POAF (odds ratio [OR]: 1.295, 95% CI: 1.205-1.391). However, further analyses showed that this effect was restricted to patients with a CHA2DS2-VASc score of ≥2 (OR: 1.813, 95% CI: 1.220-2.694). In multivariate analysis of the CHA2DS2-VASc components, age ≥75 (OR: 3.737, 95% CI: 2.702-5.168), age 65 to 74 (OR: 2.126, 1.701-2.658), hypertension (OR: 1.310, 95% CI: 1.051-1.633), and cerebrovascular accident (OR: 1.807, 95% CI: 1.197-2.726) were independent predictors of POAF. However, the association between POAF and female sex, diabetes mellitus, congestive heart failure, and vascular disease was not statistically significant. CONCLUSIONS: CHA2DS2-VASc score is a useful tool for the prediction of POAF after isolated CABG. However, the risk should be interpreted cautiously, since the risk score's promising effect relies on only several of its components.

Effect of Different Blood Groups on Long-Term Outcomes of Surgical Revascularisation.

BACKGROUND: ABO blood groups are considered to be associated with cardiovascular disease. Nonetheless, the definite effect of ABO blood groups on the clinical outcome of coronary artery bypass graft surgery (CABG) is still undetermined. We evaluated whether ABO blood groups can predict long-term major adverse cardiocerebrovascular events (MACCE) in CABG patients. METHOD: In this retrospective cohort study, we retrieved the clinical files of eligible patients treated with isolated CABG in our hospital between March 2007 and March 2016. We divided the patients into four ABO subgroups. The primary study endpoints were the occurrence of all-cause mortality and MACCE during long-term follow-ups. We used Cox regression survival analysis to define the association of ABO blood groups with the occurrence of MACCE. RESULTS: Of 17,892 patients who underwent isolated CABG, 17,713 (mean age, 61.19±9.47 years, 74.6% male) were successfully followed, and their data used in the final analysis. Our multivariable analysis demonstrated that patients with different blood groups had similar 5-year mortality and 5-year MACCE. CONCLUSIONS: Our findings suggest that in patients who underwent CABG, ABO blood groups were not associated with long-term MACCE.

Comparison of Outcomes with Midodrine and Fludrocortisone for Objective Recurrence in Treating Syncope (COMFORTS trial): Rationale and design for a multi-center randomized controlled trial.

BACKGROUND: The cornerstone of the treatment of vasovagal syncope (VVS) is lifestyle modifications; however, some patients incur life-disturbing attacks despite compliance with these treatments which underscores the importance of pharmacological interventions. METHODS: In this open-label multi-center randomized controlled trial, we are going to randomize 1375 patients with VVS who had ≥2 syncopal episodes in the last year into three parallel arms with a 2:2:1 ratio to receive midodrine, fludrocortisone, or no medication. All patients will be recommended to drink 2 to 3 liters of fluids per day, consume 10 grams of NaCl per day, and practice counter-pressure maneuvers. In medication arms, patients will start on 5 mg of midodrine TDS or 0.05 mg of fludrocortisone BD. After one week the dosage will be up-titrated to midodrine 30 mg/day and fludrocortisone 0.2 mg/day. Patient tolerance will be the principal guide to dosage adjustments. We will follow-up the patients on 3, 6, 9, and 12 months after randomization. The primary outcome is the time to first syncopal episode. Secondary outcomes include the recurrence rate of VVS, time interval between first and second episodes, changes in quality of life (QoL), and major and minor adverse drug reactions. QoL will be examined by the 36-Item Short Form Survey questionnaire at enrollment and 12 months after randomization. CONCLUSION: The COMFORTS trial is the first study that aims to make a head-to-head comparison between midodrine and fludrocortisone, against a background of lifestyle modifications for preventing recurrences of VVS and improving QoL in patients with VVS.

Cost-effectiveness analysis of mitral valve repair with the MitraClip delivery system for patients with mitral regurgitation: a systematic review.

To assess the cost-effectiveness of mitral valve repair with the MitraClip delivery system for patients with mitral regurgitation and heart failure, a systematic literature search was conducted in various electronic databases to January 3, 2020. Eligibility criteria are the population (patients with mitral regurgitation (MR)), intervention (transcatheter mitral valve repair using the MitraClip), comparator (conventional medical treatment), outcomes, and designs (Model-based or trial-based full economic evaluations).The quality of included studies was assessed using the CHEERS checklist. Mortality and survival rate, quality-adjusted life year (QALY), life years gained (LYG), total cost, and the incremental cost-effectiveness ratio (ICER) regarding the use of MitraClip System were considered as the key outcomes. Eight articles were eligible for full-text assessment. Ultimately, a total of seven studies were considered in the current systematic review. Results demonstrated that MitraClip reduces mortality rate and increases survival rate. The mortality rate at 1 year and 10 years was 16.7% versus 29.77% and 70.9% versus 98.8%, respectively. Total cost data based on 2019 USD show that the MitraClip has the highest cost in the USA ($121,390) and the lowest cost in Italy ($33,062). The results showed that in all selected countries, willingness-to-pay (WTP) thresholds are upper than the cost per QALY; also, the highest ICER for the MitraClip is in the USA ($55,600/QALY) and the lowest in Italy ($10,616/QALY). To conclude, evidence from this systematic review suggests that MitraClip Delivery System improved both life expectancy and QALY compared with medical treatment in patients at high surgical risk and it was also a cost-effective treatment option for patients with mitral regurgitation.

Cost-effectiveness of cardiac resynchronization therapy plus an implantable cardioverter-defibrillator in patients with heart failure: a systematic review.

INTRODUCTION: Heart failure (HF) is an unusual heart function that causes reduction in cardiac or pulmonary output. Cardiac resynchronization therapy (CRT) is a mechanical device that helps to recover ventricular dysfunction by pacing the ventricles. This study planned to systematically review cost-effectiveness of CRT combined with an implantable cardioverter-defibrillator (ICD) versus ICD in patients with HF. METHODS: We used five databases (NHS Economic Evaluation Database, Cochrane Library, Medline, PubMed, and Scopus) to systematically reviewed studies published in the English language on the cost-effectiveness of CRT with defibrillator (CRT-D) Vs. ICD in patients with HF over 2000 to 2020. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was applied to assess the quality of the selected studies. RESULTS: Five studies reporting the cost-effectiveness of CRT-D vs ICD were finally identified. The results revealed that time horizon, direct medical costs, type of model, discount rate, and sensitivity analysis obviously mentioned in almost all studies. All studies used quality-adjusted life years (QALYs) as an effectiveness measurement. The highest and the lowest Incremental cost-effectiveness ratio (ICER) were reported in the USA ($138,649per QALY) and the UK ($41,787per QALY), respectively. CONCLUSION: Result of the study showed that CRT-D compared to ICD alone was the most cost-effective treatment in patients with HF.

Sex and age difference in risk factor distribution, trend, and long-term outcome of patients undergoing isolated coronary artery bypass graft surgery.

BACKGROUND: Preoperative coronary artery disease risk factors (CADRFs) distribution and pattern may also have an important role in determining major adverse cardiovascular events (MACEs). In this study, we aimed to evaluate the CADRFs distribution and trend over 10 years and also the long-term outcome of CABG in different age-sex categories. METHOD: In this registry-based serial cross-sectional study, we enrolled 24,328 patients who underwent isolated CABG and evaluated the prevalence of CADRFs according to sex and age. We used inverse probability weighting (IPW) to compare survival and MACE between the sexes. We also used Cox regression to determine each CADRFs effect on survival and MACEs. RESULTS: In general, DLP (56.00%), HTN (53.10%), DM (38.40%), and positive family history (38.30%) were the most frequent risk factors in all patients. Prevalence of HTN, DLP, DM, obesity, and positive family history were all higher in women, all statistically significant. The median follow-up duration was 78.1 months (76.31-79.87 months). After inverse probability weighting (to balance risk factors and comorbidities), men had lower MACEs during follow-up (HR 0.72; 95% CI 0.57-0.91; P value 0.006) and there was no significant difference in survival between sexes. DM and HTN were associated with higher mortality and MACEs in both sexes. CONCLUSION: Although DLP is still the most frequent CADRF among the CABG population, the level of LDL and TG is decreasing. Women experience higher MACE post CABG. Therefore, health care providers and legislators must pay greater attention to female population CADRFs and ways to prevent them at different levels.