Effects of Triamterene in Hospitalized Patients with Heart Failure and Diuretic Resistance: A Randomized Clinical Trial.

Due to the potential benefits of triamterene in diuretic resistance, this study was performed to assess whether triamterene add-on to the standard treatment of heart failure (HF)-related diuretic resistance improves outcomes. A randomized clinical trial was performed on 45 hospitalized patients with HF with reduced ejection fraction who had diuretic resistance. Patients were randomized to receive either triamterene 50 mg plus hydrochlorothiazide 25 mg (n = 23) or hydrochlorothiazide 50 mg alone (n = 22) until hospital discharge. The primary outcomes were changes in weight and fluid input-to-output ratio. Secondary outcomes were respiratory rate, hospitalization duration, serum sodium and potassium, estimated glomerular filtration rate, creatinine, and blood urea nitrogen levels during the study period. The mean (standard deviation) of weight changes was not significantly different in the intervention and the control groups (-6.3 [4.8] vs -4.8 [2.4] kg, respectively; P = .1). No significant differences were shown in input-to-output changes between the 2 groups (208.0 [243.4] in the intervention and 600.2 [250.3] in the control group; P = .4). Although the respiratory rate of triamterene-treated patients decreased, the difference did not reach statistical significance (P = .2). Other secondary outcomes were also similar in both groups. This study did not support the use of triamterene as an add-on therapy for patients with HF-related diuretic resistance.

Effects of underlying heart failure on outcomes of COVID-19; a systematic review and meta-analysis.

Background: The risk for worse outcomes of COVID-19 (Coronavirus 2019 disease) is higher in patients with cardiac conditions. In this study, we aim to investigate the risks of COVID-19-induced conditions in cases with underlying heart failure. Methods: We systematically searched PubMed, Scopus, Ovid, ProQuest, Web of Science, and the Cochrane library, to collect the English language articles that investigated patients with underlying heart failure who get infected by COVID-19. The second version of comprehensive meta-analysis (CMA.2) software was used to conduct the meta-analysis. Results: From 5997 publications, our eligibility criteria were met by 27 studies. Overall, outcomes investigated in all studies include but are not limited to mortality rate, length of hospitalization, need for Intensive care unit (ICU) admission, need for mechanical ventilation, and major cardiovascular conditions. Regarding mortality heart failure patients were more susceptible to death (OR:2.570, 95%CI: 2.085 to 3.169; p-value:<0.001). Also in heart failure patients, the risk of mechanical ventilation was higher (OR:1.707, 95%CI: 1.113 to 2.617; p-value: 0.014). Conclusion: Pre-existing heart failure is associated with the increased risk of mortality and the need for mechanical ventilation while getting infected with COVID-19. Finding an answer to determine the risk of hospitalization, length of stay, readmission rate, and multiorgan failure is necessary for further development of preventive care and making a plan for providing optimal healthcare facilities for these patients.

Novel diagnostic potential of miR-1 in patients with acute heart failure.

BACKGROUND: A number of circulating micro-ribonucleic acids (miRNAs) have been introduced as convincing predictive determinants in a variety of cardiovascular diseases. This study aimed to evaluate some miRNAs' diagnostic and prognostic value in patients with acute heart failure (AHF). METHOD: Forty-four AHF patients were randomly selected from a tertiary heart center, and 44 healthy participants were included in the control group. Plasma levels of assessed miRNAs, including miR -1, -21, -23, and -423-5-p were measured in both groups. The patients were followed for one year, and several clinical outcomes, including in-hospital mortality, one-year mortality, and the number of readmissions, were recorded. RESULTS: An overall 88 plasma samples were evaluated. There was no significant difference in terms of demographic characteristics between the AHF and healthy groups. Our findings revealed that mean levels of miR-1, -21, -23, and -423-5-p in AHF patients were significantly higher than in the control group. Although all assessed miRNAs demonstrated high diagnostic potential, the highest sensitivity (77.2%) and specificity (97.7%) is related to miR-1 for the values above 1.22 (p = 0.001, AUC = 0.841; 95%CI, 0.751 to 946). Besides, the levels of miR-21 and -23 were significantly lower in patients with ischemia-induced HF. However, the follow-up data demonstrated no significant association between miRNAs and prognostic outcomes including in-hospital mortality, one-year mortality, and the number of readmissions. CONCLUSION: The result of our study demonstrated that miR-1, -21, -23, and -423-5-p can be taken into account as diagnostic aids for AHF. Nevertheless, there was no evidence supporting the efficacy of these miRNAs as prognostic factors in our study.

Impact of Melatonin and Branched-Chain Amino Acids Cosupplementation on Quality of Life, Fatigue, and Nutritional Status in Cachectic Heart Failure Patients: A Randomized Controlled Trial.

Background: Cardiac cachexia (CC) adversely affects the lifestyle of heart failure (HF) patients. The current study examined the impact of melatonin cosupplementation and branched-chain amino acids (BCAAs) on quality of life (QoL), fatigue, and nutritional status in cachectic HF patients. Methods: In this trial, 84 CC patients were randomized to melatonin, BCAAs, or coadministration (both) as intervention groups and a control group over 8 weeks. At baseline and postintervention, QoL, fatigue, and nutritional status were assessed. Results: After intervention, improvement in the overall and physical dimensions of QoL and appetite score were found to be statistically significant in the BCAAs (P < .001) and the melatonin+BCAAs (P < .001) groups compared with the placebo group. The emotional dimension score was significantly lower in the BCAAs group compared with the placebo group (P = .001). There was a statistically significant improvement in fatigue severity in all 3 intervention groups compared with the placebo group. The nutrition risk index (NRI) score increased significantly only in the melatonin group (P = .015), and there was no significant difference between the other groups (P = .804). Conclusions: Cosupplementation with BCAAs and melatonin improved QoL, fatigue status, and appetite in cachectic HF patients but did not affect NRI.

Elevated serum levels of S100A1 and zinc α2-glycoprotein in patients with heart failure.

BACKGROUND AND AIMS: Heart failure (HF) is a growing concern worldwide. S100A1 and zinc α2-glycoprotein (ZAG) play an important role in heart function. We examined serum levels of S100A1 and ZAG in HF patients and their association with anthropometric indices and body composition. METHODS AND RESULTS: Sixty-four patients with HF, mean age 56.2, 48 male and 16 females, with ejection fraction <30-35%, were recruited from Shahid Madani Heart Hospital in Tabriz, Iran, from April to October 2019. Two groups, cachexia (n = 32) and non-cachexia (n = 32), which were divided based on weight loss of at least 7.5% in the last six months, were compared with the control group (n = 26). S100A1 and ZAG serum levels were determined by ELISA. Serum median (min-max) levels of S100A1 and ZAG were significantly greater in HF patients [326 (184.8-635.2) and 150.4 (61.5-520.7)] than healthy controls [265.4 (43.6-658.8) and 119.8 (16.7-533)], both p = 0.001. S100A1 Serum levels in cachexia group was significantly higher than non-cachexia group [331 (245.6-469.6) vs. 318 (184.8-635.2), p = 0.03]. A strong positive association was observed between S100A1 and ZAG serum levels in patients (r = 0.70, p < 0.0001). Serum levels of these two proteins negatively and significantly associated with BMI (r = -0.25, p = 0.044 and r = -0.28, p = 0.024, respectively) and arm circumference (r = -0.26, p = 0.037 and r = -0.25, p = 0.047, respectively). CONCLUSION: The results indicate that S100A1 and ZAG are likely to contribute to the pathogenesis of HF disease and weight loss, as well as the strong association between S100A1 and ZAG possibly indicating a similar mechanism of action for these two proteins.

Association of mean platelet volume with echocardiographic findings in patients with severe rheumatic mitral stenosis.

Introduction: Rheumatic heart disease (RHD) is a relatively common cause of mortality among patients in the developing countries, and pure mitral valve failure is the most common form of RHD. An increase in the mean platelet volume (MPV) is considered as an independent risk factor for many cardiovascular diseases. This study aimed to evaluate the association of MPV with echocardiographic findings in patients with severe rheumatic mitral stenosis. Methods: In a descriptive, analytical study, 100 patients with severe rheumatic mitral stenosis referred to Shahid Madani hospital of Tabriz University of Medical Sciences and 100 age & sex-matched healthy individuals were included the study. MPV and echocardiographic findings including Wilkins score, left ventricular ejection fraction (LVEF), pulmonary artery systolic pressure, and left atrial spontaneous echo contrast (LASEC) were evaluated in both groups. Results: MPV in the case group was 10.45±0.98 and in the control group was 9.88±0.83. MPV in the patient's groups was significantly higher than the control group (P = 0.001). Also, MPV in patients with positive LASEC findings was 10.69 ± 1.01 and in patients with negative LASEC findings was 10.25 ± 0.91. The difference was found to be statistically significant (P = 0.028). Conclusion: Patients with rheumatic mitral stenosis has a higher MPV compared to the healthy individuals, and it is associated with LASEC sign seen in echocardiography.

The association between severe mitral stenosis and the size of the aortic root and the ascending thoracic aorta.

OBJECTIVE: The aim of this study was to examine the role of isolated rheumatic mitral stenosis (MS) in remodeling of the aorta at various locations. METHODS: In this prospective study, patients who were to undergo transesophageal echocardiography for various indications were screened. The study participants were classified into 2 groups according to the presence of MS with a valve area ≤1.5 cm2. Factors associated with the index dimensions of the aorta at the levels of the annulus, root, sinotubular junction (STJ), and the proximal ascending portion (5 cm from the annulus) were evaluated. Multivariate linear models were constructed including factors that affect the size of the aorta at any of the aforementioned levels. Pearson's correlation coefficient was used to investigate the association between mitral valve area, mitral valve gradient, and dimensions of the aorta. RESULTS: A total of 179 men and 354 women were enrolled. Eighty-four patients had MS (15.8%). The patients with MS were younger and less likely to have hypertension. In univariate analysis, patients with MS had a smaller annulus and STJ (p=0.003 and p=0.043, respectively). Multivariate analysis indicated that MS was correlated with a smaller indexed size of the aortic annulus, yielding a regression coefficient value of 0.541 (p=0.005). CONCLUSION: The presence of significant stenosis at the level of the mitral valve is associated with a smaller diameter in the aortic annulus. It is yet to be clarified whether this phenomenon occurs due to chronic, long-standing, low stroke volume or involvement of the aortic annulus in the fibrotic process of mitral disease.

Fine versus coarse atrial fibrillation in rheumatic mitral stenosis: The impact of aging and the clinical significance.

BACKGROUND: Atrial fibrillation (AF) as the most rhythm disturbance in patients with rheumatic mitral stenosis (MS), is classified in to coarse and fine subtypes according to the height of fibrillatory wave amplitude. The aim of this study is to identify the factors associated with the presence of fine versus coarse morphology in patients with rheumatic MS. METHODS: In this cross-sectional study, patients with confirmed diagnosis of severe rheumatic MS admitted between March 2013 and March 2017 were screened. Patients were categorized to sinus rhythm (SR) and AF rhythm (coarse and fine subtypes) groups according to the admission electrocardiogram. The association between various clinical and echocardiographic factors and the development of fine versus coarse AF were examined. RESULTS: Among 754 patients with the diagnosis of rheumatic MS, 288 (198 female) were found to have AF (38%). Among them 206 (71.5%), and 82 (28.5%) patients had fine and coarse morphology respectively. Patient in these two groups were quite similar in terms of echocardiographic parameters and comorbidities. However, patients with fine morphology AF were significantly older. (p-Value=.007). CONCLUSION: Coarse morphology of AF is common in patients with rheumatic MS. While echocardiographic or most clinical parameters do not seem to associate with the occurrence of coarse or fine morphology, age seems to be the only independent factor correlated with the presence of fine subtype of AF in this population.

An Evidence-Based Review of Off-Label Uses of Polidocanol.

BACKGROUND: Polidocanol is approved for its competence in the treatment of varicose veins and spider veins; however, unfortunately, many of its off-label uses are still underappreciated. OBJECTIVE: Lack of an appropriate comprehensive review for off-label uses of this medication troubles physicians about making evidence-based decisions on prescribing it for its various outstanding off-label uses. This article attempts to provide physicians with the latest information concerning successful and unsuccessful use of polidocanol as an alternative treatment for esophageal and gastric varices, tendinopathy and epicondylitis, vascular malformations, varicocele, hydrocele and spermatocele, aneurysmal bone cysts, itching, management of gastrointestinal bleeding, simple renal cysts, reducing the incidence and severity of radio-induced dermatitis and hemorrhoids. METHOD: The two databases of MEDLINE and Cochrane Library were searched for all human English studies, published in January 2006 to November 2017, which contained the keyword of "polidocanol" or its alternative MeSH terms. RESULTS: Our search identified a total number of 597 articles. Those articles that were only discussing the approved uses of polidocanol were excluded and the remaining 116 articles were reviewed. Eleven major and 30 minor off-label uses were found within included studies. CONCLUSION: Numerous successful administrations of this drug in a variety of clinical conditions lead to promising perspectives toward it. Sclerotherapy with polidocanol as a minimal-invasive method (having similar outcomes like the prevalent surgeries) may reduce the rate of complications. Furthermore, for determining the most appropriate method and dosage, randomized clinical trials are needed, confirming and providing more clear instructions for different conditions.

Immediate Postoperative Complications in Patients Undergoing CABG; Investigating the Role of Prior Coronary Stenting.

INTRODUCTION: Approximately 15 to 30% of patients undergoing percutaneous coronary intervention (PCI) will require repeated revascularization. There is an ongoing debate concerning the impact of prior PCI on subsequent coronary artery bypass graft (CABG) surgery. This study sought to compare immediate post-CABG complications between patients with and without previous coronary stenting. METHODS: A total of 556 CABG candidates including 73 patients with previous coronary stenting and 483 patients without prior stenting were enrolled in this retrospective-prospective study. Demographic information, cardiac markers (CK-MB, Troponin T), and postoperative data including inotrope administration, intra-aortic balloon pump (IABP) use, bleeding, pathological electrocardiography (ECG) changes, and overall complications were compared between the two groups. RESULTS: The mean age of the patients in stented group was significantly higher than that in unstented group (63.49±7.71 vs. 61.37±9.80 years, p=0.05). The mean serum level of Troponin T 12 h postoperation was significantly higher in the same group (323.26±33.16 vs. 243.30±11.52 ng/dL; p=0.03). Comparing the stented and unstented groups, the rates of inotrope use (17.8% vs. 7.2%; p=0.003), significant bleeding (15.1% vs. 4.3%; p=0.001), and overall complications (32.9% vs. 11.6%; odds ratio: 3.74 with 95% confidence interval of 2.13-6.55, p<0.001) were significantly higher in the former group. The association between overall complications and prior stenting was independent (odd ratio: 3.06). No significant connections were found between postoperative complications and stent number or type. CONCLUSION: A positive history of previous coronary stenting significantly increases the risk of immediate post-CABG complications.

Epicardial and pericardial fat volume correlate with the severity of coronary artery stenosis.

INTRODUCTION: Epicardial fat volume (EFV) has been reported to correlate with the severity of coronary artery disease (CAD). Pericardial fat volume (PFV) has recently been reported to be strongly associated with CAD severity and presence. We aimed to investigate the relationship between EFV and PFV with severity of coronary artery stenosis in patients undergoing 64-slice multi-slice computed tomography (MSCT). METHODS: One hundred and fifty one patients undergoing MSCT for suspected CAD were enrolled. Non-enhanced images were acquired to assess calcium score. Contrast enhanced images were used to quantify EFV, PFV and severity of luminal stenosis. RESULTS: Coronary artery stenosis was mild in 25 cases (16.6%), moderate in 58 cases (38.4%) and severe in 68 cases (45%). With increase in severity of coronary artery stenosis, there was significant increase in PFV, EFV as well as epicardial fat thickness in right ventricle free wall in basal view and epicardial fat thickness in left ventricle posterior wall in mid and apical view. There was significant linear correlation between PFV with coronary calcification score (r=0.18, P=0.02), between coronary artery stenosis severity and PFV (r=0.75, P<0.001), EFV (r=0.79, P<0.001), apical epicardial fat thickness in right ventricle free wall (r=0.29, P<0.001), Mid (r=0.28, P<0.001) and basal (r=0.23, P=0.004) epicardial fat thickness in left ventricle posterior wall. CONCLUSION: PFV, EFV and regional epicardial thickness are correlated with severity of CAD and could be used as a reliable marker in predicting CAD severity.

Study of cognitive disorders in stroke-free patients with a history of atrial fibrillation.

Atrial fibrillation is associated with cerebral stroke, congestive heart insufficiency and mortality. The present study aimed at evaluating of cognitive disorders in patients with history of atrial fibrillation without cerebral stroke. In a case-control study, 100 patients with first-ever atrial fibrillation seizure without history of cerebral stroke were evaluated. One hundred healthy subjects with normal sinus rhythm matched with the patients in terms of age and gender were regarded as the control group. The case and control groups were followed up for at least one year after occurring of atrial fibrillation. Cognitive disorders were evaluated at the last visit. The case group was consisted of 51 men and 42 women with mean age of 71.08 +/- 5.35 years and there were 53 men and 43 women with mean age of 71.34 +/- 5.04 years in the control group. Previous history of hypertension, diabetes mellitus, hyperlipidemia, hypercholesterolemia, smoking, consuming of alcohol and warfarin in the case group were 49.5, 23.7, 18.3, 31.2, 14, 7.5 and 9.7% and in the control group 6.4, 35.4, 24, 36.5, 21.9, 13.5 and 12.5%, respectively. In this regard, there was not statistically meaningful difference between these two groups. Dementia was detected in 3 (3.2%) of the case and 1 (1%) of the control group subjects (p = 0.29). Comparing two groups with and without dementia demonstrated that there was not any meaningful risk factor. According to the results, dementia in patients with positive history of atrial fibrillation was more than normal population.

Diastolic Function Evaluations by Tissue Doppler Imaging in Patients With Mitral Valve Prolapse.

BACKGROUND: Tissue Doppler imaging (TDI) is a new echocardiographic imaging technique that is believed to be superior to older conventional techniques in assessing abnormalities of cardiac function in many conditions affecting the heart. There are very limited data regarding the role of TDI in evaluating patients with mitral valve prolapse (MVP). Current study evaluates diastolic function in patients with MVP by this method. METHODS: From November 2009 to April 2011, one hundred and ten adults matched for age and sex and without structural heart disease were studied in two groups, with and without MVP, at Madani Heart Center, Tabriz, Iran. TDI was performed at the basal-lateral wall and S, E, E', A, and A' velocities, as well as the E/A and E'/A' ratios were measured. Mitral annular systolic velocity and early diastolic (E') velocities were measured lateral corner of mitral valve in apical 4-chamber view. RESULTS: Patients with MVP had higher left atrium volume (42.31 ± 10.47 vs. 35.19 ± 9.15 cm3; P < 0.001) and deceleration time (186.70 ± 26.00 vs. 176.89 ± 20.36 ms; P = 0.03). Diastolic dysfunction, although seemed more prevalent in MVP group (14.54%) than normal subjects (5.45%), the difference was not statistically significant between groups (P = 0.11). CONCLUSION: Left atrial volume and deceleration time of mitral valve inflow was significantly higher in MVP which could be indicative of early stages of diastolic dysfunction in patients with MVP. However, larger follow-up studies are required to evaluate clinical significance of our findings in these patients.