Impact of coronary artery bypass grafting surgery on the chorioretinal biomicroscopic characteristics.

BACKGROUND: Most patients with cardiovascular disorders suffer from coronary artery diseases, which can be treated successfully using coronary artery bypass grafting (CABG). One of the unpleasant events following CABG is postoperative vision loss (POVL). Vulnerability of retinal vessels to hemodynamic changes, an expectable event following CABG, may contribute to the development of POVL, which might be associated with the changes in the choroidal and retinal structures. AIM: To investigate postoperative changes in chorioretinal and peripapillary nerve fiber layer (NFL) thickness, and progression of diabetic and hypertensive retinopathy after CABG. METHODS: In this prospective, cross-sectional study, 49 eyes in 25 candidates for CABG underwent both ophthalmic and cardiovascular examinations within 6 mo prior to and 9 mo after surgery. RESULTS: Among the study participants, 56% were male with a mean age of 62.84 years ± 10.49 years (range 33-80 years). Diabetes mellitus was observed in eight participants (32%). None of the patients suffered from postoperative anterior or posterior ischemic optic neuropathy, central retinal artery occlusion, and cortical blindness. The mean value of the preoperative best corrected visual acuity was 0.11 ± 0.10 logMAR (range, 0-0.4), which worsened to 0.15 ± 0.08 logMAR (range, 0-0.4) after CABG (P = 0.031). No significant difference was observed between the pre- and postsurgical choroidal (P = 0.853) and macular (P = 0.507) thickness, NFL thickness in the subfoveal (P > 0.999) and peripapillary areas (P = 0.659), as well as the severity of diabetic and hypertensive retinopathy. CONCLUSION: CABG may reduce visual acuity without affecting ocular structures. Postoperative vision reduction might be attributable to molecular or cellular variations, changes in visual pathway function, or central nervous system.

Is cardiac Troponin I Considered as A Predictor of In-hospital Mortality among COVID-19 Patients? A Retrospective Cohort Study.

OBJECTIVE: To describe the levels of troponin I in COVID-19 patients and its role in the prediction of their in-hospital mortality as a cardiac biomarker. METHODS: The current retrospective cohort study was performed on the clinical records of 649 COVID-19-related hospitalized cases with at leat one positive polymerase chain reaction (PCR) test in Tehran, Iran from February 2020 to early June 2020. The on admission troponin I level divided into two groups of ≤0.03ng/mL (normal) and >0.03ng/mL (abnormal). The adjusted COX-regression model was used to determine the relationship between the studied variables and patient's in-hospital mortality. RESULTS: In this study, the median age of subjects was 65 years (54.8% men) and 29.53% of them had abnormal troponin I levels. Besides, the in-hospital mortality rate among patients with abnormal troponin I levels was found to be 51.56%; whereas, patients with normal levels exhibited 18.82% mortality. Also, the multivariable analysis indicated that the risk of death among hospitalized COVID-19 patients displaying abnormal troponin I levels was 67% higher than those with normal troponin I levels (Hazard ratio=1.67, 95% confidence interval=1.08-2.56, p=0.019). CONCLUSION: It seems that troponin I is one of the important factors related to in-hospital mortality of COVID-19 patients. Next, due to the high prevalence of cardiac complications in these patients, it is highly suggested to monitor and control cardiac biomarkers along with other clinical factors upon the patient's arrival at the hospital.

Adjunct Hypertonic Saline in Patients with Diffuse Edema Due to Heart Failure: A Randomized Double-Blinded Clinical Trial.

In patients with diuretic resistance due to heart failure, higher doses or continuous furosemide infusion and adding hypertonic saline solution (HSS) to diuretics could be effective. The goal of this study was to assess the effectiveness of hypertonic saline solution administration in weight loss of hospitalized patients with diuretic-resistant edema due to heart failure. In a randomized double-blinded clinical trial, adult patients with diffuse peripheral edema due to heart failure who were unresponsive to 80 mg of oral furosemide were enrolled. The patients were randomized into two groups. In the intervention and control groups, patients received 150 mL of HSS and normal saline, respectively. Subjects in both groups received 250 mg IV furosemide every 12 h for 48 h. The change in body weight, urine output, blood pressure, uric acid, urine osmolality, blood biochemistry, and urinary cystatin C levels were assessed. Based on defined inclusion and exclusion criteria, 28 patients, 14 in each group, were recruited. The groups were similar in demographic and baseline laboratory characteristics. A significant decrease in body weight was observed in the intervention group (P = 0.002). The change in other measured parameters, including urine output and urinary cystatin C levels, was not reached statistical significance. Our findings suggest that the administration of HSS as an adjunct to loop diuretics could provide a safe and effective treatment for increasing urine output and decreasing weight in patients with heart failure.

Prognostic Value of Blood Pressure Responsiveness in Hemodialysis for Cardiovascular Mortality, Development of A New Predictive Equation.

INTRODUCTION: Cardiovascular disease is considered as the main cause of mortality and morbidity in HD-patients and AS is a fundamental cause. This study was conducted to investigate whether intradialytic BP changes can use as a surrogate clinical marker. METHODS: Fifty-one patients on maintenance hemodialysis, for at least 12 hours per week, were included in a prospective cohort study. Intradialytic BP was measured using validated automated device. PWV was performed to assess Augmentation Index (AIx) as marker of arterial stiffness. All measurements were repeated in alive individuals after 5 years of follow-up. Patients with 5% reduction of intradialytic BP were considered as HD-responsive and Several statistical analyses were employed based on responsiveness to HD. RESULTS: After 5-year follow-up the findings demonstrated BP response to HD was an important and independent determinant of mortality (P < .05). Augmentation index (AIx) (P < .05), heart rate (P < .05), and calcium phosphate product (P < .05) as well as log PTH (P < .05) were significantly different between two responsive and non-responsive to HD. Pearson's Correlation studies revealed a significant relationship between the BP response to HD and heart rate (r = 0.4, P < .05), LVEF (r = -0.4, P < .05) and PTH (r = -0.3, P < .05). BP response to HD and log-PTH remained significant even after age and gender adjustment (P < .05). CONCLUSION: BP-response to HD can use as a clinical and surrogate marker of AS which is significantly associated with mortality and LVEF. Arterial stiffness and intradialytic BP can predict the changes in Ejection Fraction (EF). DOI: 10.52547/ijkd.6810.

Dual antiplatelet therapy before coronary artery bypass grafting in patients with myocardial infarction: a prospective cohort study.

BACKGROUND: Dual antiplatelet therapy (DAPT) in patients with MI who are candidates for early coronary artery bypass grafting (CABG) can affect intraoperative and postoperative outcomes. Therefore, the aim of this study was to evaluate the effect of DAPT up to the day before CABG on the outcomes during and after surgery in patients with MI. METHODS: In this prospective cohort study, 224 CABG candidate patients with and without MI were divided into two groups: (A) patients without MI who were treated with aspirin 80 mg/day before surgery (noMI-aspirin group; n = 124) and (B) patients with MI who were treated with aspirin 80 mg/day before surgery and clopidogrel (Plavix brand) at a dose of 75 mg/day (MI-DAPT group; n = 120). Dual or mono-antiplatelet therapy continued until the day before surgery. Patients were followed to assess in-hospital and 6-months outcomes. RESULTS: The in-hospital mortality in MI-DAPT group was similar with noMI-aspirin group (OR 4.2; 95% CI 0.9-20.5; p = 0.071). The prevalence of CVA (p = 0.098), duration of hospital stay (p = 0.109), postoperative ejection fraction level (p = 0.693), diastolic dysfunction grade (p = 0.651) and postoperative PAP level (p = 0.0364) did not show difference between two groups. No mild or severe bleeding was observed in the patients. Six-month follow up showed that number of readmissions (p = 0.801), number of cases requiring angiography (p = 0.100), cases requiring re-PCI (p = 0.156), need for re-CABG (p > 0.999) and CVA (p > 0.999) did not differ between the two groups. During the 6-month follow-up, out-hospital mortality did not differ significantly between the two groups (p = 0.446). CONCLUSIONS: A 6-month follow-up showed that DAPT with aspirin and clopidogrel before CABG in patients with MI has no effect on postoperative outcomes more than mono-APT with aspirin. Therefore, DAPT is recommended in the preoperative period for these patients.

A Randomized Double Blind Placebo Controlled Trial Examining the Effects of Pentoxifylline on Contrast Induced Nephropathy Reduction after Percutaneous Coronary Intervention in High Risk Candidates.

Contrast-induced nephropathy (CIN) (known as contrast-induced acute kidney injury) occurs as a result of acute worsening of renal function following a procedure with administration of iodine contrasts agent and remains a substantial concern in clinical practices. The purpose of this study is to investigate the preventive effect of Pentoxifylline supplementation on reduction of CIN occurrence after percutaneous coronary intervention among patients who were high risk of CIN according to Mehran score. In randomized, double-blind clinical trial patients who undergo coronary angiography with Mehran Score ≥ 11 consisted of our population. Patients in a ratio 1:1, divided into two groups received saline 0.9% plus N-acetyl cysteine and Pentoxifylline 400 mg three times per day 24 h before angiography until 48 h after angiography. In control group, the patients received placebo instead of PTX in a same manner as the control group. The endpoint was the incidence of CIN defined as creatinine increase of 0.5 mg/dL within 2 days after contrast. There were no significant differences in baseline characteristics. CIN occurred in 3 (5.5%) and 4 (7.3%) patients of the both groups (Pentoxifylline and control), respectively (p = 0.69; incidence odds ratio 1.36; 95% CI 0.29-6.38). No significant differences were seen in secondary outcome measures and changes in the level of creatinine (p = 0.54). In high-risk patients undergoing coronary angiography pentoxifylline supplementation had protection effect against contrast-induced nephropathy greater than placebo based hydration, but, not supported by our data.

The role of air pollution on ST-elevation myocardial infarction: a narrative mini review.

ST-elevation myocardial infarction (STEMI) is one of the potential causes of death worldwide. In spite of substantial advances in its diagnosis and treatment, STEMI is still considered as a major public health dilemma in developed and particularly developing countries. One of the triggering factors of STEMI is supposed to be air pollutants like gaseous pollutants including, sulfur dioxide, nitric dioxide, carbon monoxide, ozone and particulate matters (PM) including, PM under 2.5 µm (PM2.5) and PM under 10 µm (PM10). Air pollution can trigger STEMI with various mechanisms such as increasing inflammatory factors and changing the heart rate or blood viscosity. In this article, we aimed to explore research in the field and discuss the relationship between air pollution and STEMI.

Comparison of coronary risk factors and angiographic findings in younger and older patients with significant coronary artery disease.

BACKGROUND: Coronary artery disease (CAD) is uncommon among young adults and may have certain characteristics that are different from those in older patients. The aim of the current study was to determine the risk factors of CAD, important laboratory data and angiographic findings in young patients with CAD and to compare them with the old patients. METHODS: Patients with typical chest pain whose CAD was confirmed by coronary angiography were included in the study. These patients were divided into 2 groups: ≥ 45 and < 45 years old; the risk factors of CAD and angiographic findings were determined in each group and further compared. RESULTS: Finally, 231 patients with CAD were included in the study. Thirty-five (30.4%) of patients younger than 45 years and 58 (50.0%) aged ≥ 45 had diabetes mellitus (P = 0.002). Statistically remarkable differences were observed between the two groups regarding hypertension (P < 0.001), myocardial infarction (P < 0.001), Gensini score Median (P < 0.001), ejection fraction in echocardiography (P < 0.001) and fasting blood sugar in laboratory data (P = 0.006). The older group, compared with the younger one, had higher left anterior descending (LAD) artery (P < 0.001), right coronary artery (RCA) (P < 0.001), 3 vessel disease (P < 0.001) and 2-vessel disease (P = 0.044); on the other hand, 1-vessel disease was higher in patients aged < 45(P < 0.001). CONCLUSION: The risk profile and angiographic findings are different in young patients with CAD compared to older patients. Young patients with CAD tend to be male with a positive familial history, but with less diabetes or hypertension. The older patients had higher 3 vessel disease, 2-vessel disease and left anterior descending (LAD) artery and right coronary artery (RCA) involvements. In contrast, 1-vessel disease was higher in young patients aged <45.

Rest 2D speckle tracking echocardiography may be a sensitive but nonspecific test for detection of significant coronary artery disease.

AIMS: To detect the significance of coronary artery disease in the patients, who are suspected, was assumed to be one of the advantages of 2D STE, as a novel non-invasive imaging modality with acceptable accuracy. METHODS: In this study, 216 patients who were suspected to have coronary artery disease and candidate for coronary angiography, underwent rest two-dimensional speckle tracking echocardiography (2D STE) and negative global systolic longitudinal strain was evaluated. RESULTS: Negative global systolic left ventricular longitudinal strain under 18% in rest 2D-STE was significantly prevalent in patients with significant CAD in coronary angiography (P value<0.0001).Our results revealed sensitivity of 91.1%, specificity of 63.0%, positive predictive value of 80.4%, negative predictive value of 81.0% and accuracy of 80.5% for rest 2D-STE in detection of significant CAD. CONCLUSION: Here in we showed that rest Two-dimensional speckle tracking echocardiography could be a sensitive but nonspecific imaging modality to determine significant coronary artery disease. Future studies with large size will reveal more detailed findings.

AV nodal reentrant tachycardia with a 2:1 right bundle branch block missed as bidirectional ventricular tachycardia in the first superficial evaluation.

A 95-year old woman was admitted to our emergency unit because of acute abdominal pain. After urgent surgery according to the acute abdomen, she was referred to intensive care unit (ICU) of the emergency unit as she was intubated. It was developed a run of new arrhythmia which was diagnosed by cardiology resident as bidirectional ventricular tachycardia due to beat to beat changing the axis of the QRS. However, a second and more precise evaluation of the abnormal ECG suggested a narrow supraventricular tachycardia, most probably AV nodal reentrant tachycardia with a 2:1 right bundle branch block.

The Assessment of short-term effect of L-Citrulline on endothelial function via FMD to NMD ratio in known CAD patients: A randomized, cross-over clinical trial (Clinical trial number: NCT02638727).

BACKGROUND: Recent studies have confirmed the essential and paramount role of the L-Citrulline on the nitric oxide regulation and the endothelial function improvement. MATERIALS AND METHODS: In this cross-over clinical trial, thirty patients, diagnosed with coronary artery disease (CAD) and flow mediated dilation to nitroglycerin dependent vasodilation (FMD/NMD) ratio less than 1, were included. The patients were randomly divided into two groups of 15 patients and underwent treatment by L-Citrulline or placebo for 15 days, in 2 step protocol. The indicators of assessment in the current study were the ratio of the FMD/NMD and FMD value. RESULTS: In the current cross-over clinical trial, the mean of FMD to NMD ratio and mean FMD value of all patients before starting the protocol were 0.91 ± 0.08 and 4.04 ± 0.51 mm, respectively. The final results of study showed that following L-Citrulline administration, mean FMD to NMD ratio and mean FMD value were enhanced to: 1.03 ± 0.09 and 4.96 ± 0.72 mm, respectively, which were statistically significant (P<0.001 and P<0.001, respectively). However, following placebo administration, mean FMD to NMD ratio and mean FMD value were receded to: 0.92 ± 0.09 and 4.06 ± 0.22 mm, respectively, which were not statistically significant (P = 0.75 and P = 0.89, respectively). Moreover, the improvement of mean FMD to NMD ratio (0.12 ± 0.02) and mean FMD value (0.92 ± 0.16 mm), following L-Citrulline administration, were statistically significant in comparison with the change of mean FMD to NMD ratio (0.01 ± 0.002) and mean FMD value (0.02 ± 0.003), following placebo administration (P<0.001 and P<0.001, respectively). CONCLUSION: L-Citrulline treatment can lead to improvement of the endothelial function in patients diagnosed with CAD which are assessed via FMD to NMD ratio FMD value enhancements.

Stent-assisted coiling of large common femoral artery pseudoaneurysm following coronary artery catheterization: an uncommon and novel approach.

The femoral artery pseudoaneurysm is a disturbing groin complication associated with the femoral arterial access site used for invasive cardiovascular interventions. We present a 39 year old man who developed a huge right common femoral artery pseudoaneurysm, following diagnostic coronary artery catheterization, which was successfully managed with stent-assisted coiling, an emerging and narrative option in invasive percutaneous approaches to femoral artery pseudoaneurysm.

Lipid Peroxidation and Antioxidant Status in Patients with Medullary Thyroid Carcinoma: A Case-Control Study.

INTRODUCTION: Oxidative stress or oxidant/antioxidant imbalance has a crucial role in the pathogenesis of some diseases like cancer. Medullary thyroid carcinoma (MTC) originates in the thyroid parafollicular cells and includes 3-4% of the malignant neoplasms that have an effect on this gland. The aetiology of MTC has not been clarified. However, oxidative stress may be one of the factors involved. AIM: The aim of the current study was to evaluate the antioxidant enzyme activity of catalase (CAT), Glutathione (GSH), total antioxidant capacity (TAC) and the levels of the lipid peroxidation product malondialdehyde (MDA) in blood samples of MTC patients as compared to healthy controls. MATERIALS AND METHODS: A case-control study was designed enrolling patients with confirmed MTC diagnosis and age-and sex group matched healthy volunteers referred to the clinic of the Research Institute for Endocrine Sciences, Tehran, Iran from April 2013 to July 2015. Fasting blood samples were taken for study. Catalase, GSH, MDA and TAC levels were measured by colorimetry using commercial kits (ZellBio GmbH, Germany). Data were analysed using SPSS 17 software, comparing mean±SD through t-test and difference between proportions through chi-square. RESULTS: No statistical difference was observed in the demographic characteristic between cases and controls. The final MTC group included 40 males and 45 females with a mean age of 30±12.9 year, and the control group 40 males and 47 females, with a mean age of 31.2±12.3 year. Anthropometric parameters, dietary and thyroid hormones levels (T3, T4 and TSH) were similar. Serum TAC (p=0.015), GSH (p=0.029) and CAT (p<0.001) levels were found to be significantly lower in the MTC patients, while serum MDA levels were significantly higher in MTC patients than controls (p<0.001). CONCLUSION: These preliminary findings suggest that oxidant/antioxidant imbalance may be associated with or possibly indicate an increased risk to medullary thyroid carcinoma. Further studies are needed to explore these findings.

Simultaneous thrombosis of the left anterior descending artery and the right coronary artery in a 34-year-old crystal methamphetamine abuser.

This case report underscores that crystal methamphetamine abuse is an important cause of multivessel coronary thrombosis and raises doubts about the therapeutic options. The patient was a 34-year-old smoker and crystal methamphetamine abuser with no significant medical history, who presented with retrosternal chest pain associated with cold sweats. Twelve-lead electrocardiogram revealed diffuse ST-segment elevation in I, II, AVL, AVF, and V 2-6 leads. He underwent urgent coronary angiography and it showed Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow in coronary arteries and presence of a thrombus in the left anterior descending artery (LAD) and the right coronary artery (RCA). The patient underwent medical therapy with antiplatelet agents and anticoagulants. Repeat coronary angiography after three months of dual therapy with warfarin and aspirin did not show any thrombus or any significant lesion in the RCA and the LAD having TIMI grade 3 flow.

Diffuse pulmonary hemorrhage after fibrinolytic therapy for acute myocardial infarction in a cocaine abuser patient.

We report a 45-year-old man with antroseptal myocardial infarction who developed bilateral basal alveolar infiltrates after initiating the fibrinolytic therapy. Although thrombolytic therapy with streptokinase is generally used in the course of acute myocardial infarction and has diminished morbidity and mortality, pulmonary hemorrhage is an uncommon, but a potentially life-threatening complication that should be regarded as one of the differential diagnoses of pulmonary infiltrates or dropping hemoglobin with no apparent bleeding site.

Risk Factors of Reperfusion Failure following Primary Angioplasty for ST-Segment Elevation Myocardial Infarction (STEMI).

BACKGROUND: Although percutaneous coronary intervention (PCI) improves outcomes compared to thrombolysis, a substantial number of ST-elevation myocardial infarction (STEMI) patients do not achieve optimal myocardial reperfusion. This study was designed to evaluate factors related to suboptimal myocardial reperfusion after primary PCI in patients with STEMI. METHODS: Totally, 155 patients (124 men; mean age = 56.6 ± 11.03 years, range = 31- 85 years) with STEMI undergoing primary PCI were retrospectively studied. Additionally, the relationships between the occurrence of reperfusion failure and variables such as age, sex, cardiac risk factors, family history, Body Mass Index, time of symptom onset, ejection fraction, previous PCI, coronary artery bypass graft surgery or previous myocardial infarction, and angiographic data were analyzed. RESULTS: Procedural success was 97.1% and complete ST resolution occurred in 43.2%. Age; cardiac risk factors; family history; body mass index; previous MI, coronary artery bypass graft surgery, or PCI; and use of thrombectomy device and GPIIb/IIIa inhibitor were not the determining factors (p value > 0.05). According to our multivariate analysis, time of symptom onset (OR [95% CI]: 045 [0.2 to 0.98]; p value = 0.044) and ejection fraction (OR [95% CI]:0.37 [0.26 to .091]; p value = 0.050) had reverse and male gender had direct significant associations with failed reperfusion (OR [95% CI]: 0.34 [0.11 to 1.08]; p value = 0.068). More degrees of ST resolution occurred when the right coronary artery was the culprit vessel (p value = 0.001). The presence of more than three cardiac risk factors was associated with failed reperfusion (p value = 0.050). CONCLUSION: Considering the initial risk profile of patients with acute STEMI, including time of symptom onset and ejection fraction, as well as the accumulation of cardiac risk factors in a given patient, we could predict failed myocardial reperfusion to design a more aggressive therapeutic strategy.

Ischemia detection by electrocardiogram in wavelet domain using entropy measure.

BACKGROUND: Ischemic heart disease is one of the common fatal diseases in advanced countries. Because signal perturbation in healthy people is less than signal perturbation in patients, entropy measure can be used as an appropriate feature for ischemia detection. METHODS: Four entropy-based methods comprising of using electrocardiogram (ECG) signal directly, wavelet sub-bands of ECG signals, extracted ST segments and reconstructed signal from time-frequency feature of ST segments in wavelet domain were investigated to distinguish between ECG signal of healthy individuals and patients. We used exercise treadmill test as a gold standard, with a sample of 40 patients who had ischemic signs based on initial diagnosis of medical practitioner. RESULTS: The suggested technique in wavelet domain resulted in the highest discrepancy between healthy individuals and patients in comparison to other methods. Specificity and sensitivity of this method were 95% and 94% respectively. CONCLUSIONS: The method based on wavelet sub-bands outperformed the others.