The Comparison of the Initial TIMI Flow Grade in Acute ST-Elevation Myocardial Infarction Patients Receiving Ticagrelor vs. Clopidogrel before Undergoing Primary Percutaneous Coronary Intervention: A Prospective Cohort Study.

Objective: Primary percutaneous coronary intervention (PCI) is the best treatment for acute ST-elevation myocardial infarction (STEMI). Evidence is in favor of ticagrelor over clopidegrel in STEMI patients regarding the reduction of stent thrombosis risk during and after PCI. We compared initial thrombolysis in myocardial infarction (TIMI) flow in STEMI patients on ticagrelor vs. clopidogrel. Methods: This prospective cohort recruited 160 patients with acute STEMI, referred to the emergency department of Farshchian Heart Center, during March 2018-2019. Before angiography, the patients received clopidogrel (600 mg) or ticagrelor (180 mg) on top of aspirin. Initial TIMI flow was compared between the two groups as the primary outcome. A logistic regression was performed to calculate the predictors of initial TIMI flow. Analyses were performed using R, version 4.2.1. Results: In ticagrelor and clopidogrel groups, the mean ± standard deviation age of the patients was 59.46 ± 13.11 and 61.34 ± 11.08 years (p value = 0.33), respectively. In the ticagrelor and clopidogrel groups, initial TIMI flow grades were as follows: 0 : 50% and 71.2%, I: 26.2% and 16.2%, II: 12.5% and 10%, and III: 12.9% and 2.5%, respectively (p value = 0.005). Final TIMI flow grades were as follows: I: 26.2% and 16.2%, II: 7.5% and 13.8%, and III: 66.3% and 70%, respectively (p value = 0.41). Ticagrelor was associated with significantly higher initial TIMI flow grade compared to the clopidogrel group (adjusted odds ratio: 2.90 (95% CI: 1.51-5.72)). Conclusion: In STEMI patients who were candidates for primary PCI, ticagrelor administration led to a better initial TIMI flow grade compared to clopidogrel.

Relationship between Severity and Complexity of Coronary Artery Involvement and Obstructive Sleep Apnea Based on STOP-BANG Questionnaire.

Background: Obstructive sleep apnea (OSA), which has a known correlation with cardiovascular disease, is a possible risk factor of coronary artery disease (CAD) that is preventable. Aims: We sought to put lights on the relationship between OSA based on the STOP-BANG questionnaire (SBQ) and the severity and complexity of coronary artery involvement. Methods: This cross-sectional, single-center, retrospective study was conducted among 145 patients who underwent selective coronary angiography (SCA) between October 2018 and March 2019, admitted to the Tehran Heart Center, Tehran, Iran. OSA risk was assessed in patients based on SBQ categories. Also, the severity and complexity of coronary artery involvement calculated according to SYNTAX and Gensini scores. Analysis performed by statistical software SPSS 25. Results: Based on SBQ risk assessment categories, 22 (15.2%), 64 (44.1%), and 59 (40.7%) of the patients were low, intermediate, and high-risk for OSA, respectively. By comparing the means of coronary artery involvement, there was no significant difference in SYNTAX score 17.15 ± 13.67 (10.56-23.74) in low, 15.67 ± 9.78 (13.19-18.16) in intermediate, and 16.93 ± 9.21 (14.42-19.45) in high-risk groups; P value: 0.754, and Gensini score 66.4 ± 70.75 (35.04-97.77) in low, 66.21 ± 55.05 (52.45-79.96) in intermediate, 74.61 ± 56.33 (59.93-89.3) iin high risk groups; P value: 0.697 with groups of OSA risks. Also, after adjusting confounding factors, there was still no statistically significant difference in terms of coronary involvement scores. Conclusions: There was no statistically significant difference in SYNTAX and Gensini scores of different groups of OSA risk categories based on the SBQ. However, our results can't be extended into the connection between OSA and CAD.

Comparing clinical outcomes in patients with diabetes undergoing coronary artery bypass graft and percutaneous coronary intervention in real world practice in Iranian population.

BACKGROUND: Coronary artery bypass graft (CABG) is generally regarded as one the treatment options for coronary artery disease (CAD) in patients with diabetes. In recent years, with the advent of drug-eluting stents (DES), percutaneous coronary intervention (PCI) was introduced as a suitable alternative for CABG. The aim of this study was to compare the incidence of major adverse cardiac and cerebrovascular event (MACCE) during mid-term period in patients with diabetes treated with 2 revascularization strategies. METHODS: This historical cohort study was conducted on 750 consecutives patients with diabetes in a single cardiovascular center from July 2009 to March 2012 in Iran. We included previously known case of DM treated with antidiabetic medications (with or without end organ damage) and patient with preoperational evaluation FBS test > 126 (not on the day of the surgery) who were revascularized by 2 strategies. We excluded those patients whose follow-up was not possible. RESULTS: Finally, out of 697 eligible patients, 355 patients underwent a CABG and 342 underwent a PCI: 53 patients were lost to follow-up (27 in CABG and 26 in PCI groups). The mean follow-up time was 900.68 ± 462.03 days in the CABG and 782.60 ± 399.05 in PCI groups. There were 17 (9.13%) cardiac deaths in the CABG group and 8 (4.45%) in the PCI group; this difference was not significant (P = .11). There was 14 (7.58%) cerebrovascular accident in the CABG group and 4 (2.31%) in the PCI group; this difference was significant (P = .04). Moreover, the frequency of the target vessel revascularization in the CABG and PCI groups was 6 (3.32%) and 31 (17.11%) (P < .001), respectively. Myocardial infarction in the CABG group was 5 (2.77%) and 14 (7.86%) in the PCI group (P = .009). Finally, the frequency of MACCE in the CABG and PCI groups was 41(20.70%) and 47(24.16%) respectively; this difference was not statistically significant (P = .195). CONCLUSION: Patients with CABG in this study experienced more CVA, while the frequency of TVR and non-fatal MI was higher in the PCI arm.

Transient ischemic dilation or transient RV visualization in patients with normal SPECT stress myocardial perfusion imaging: Correlation with CT coronary artery calcium scoring and coronary angiography.

BACKGROUND: Ancillary findings on MPI, such as transient ischemic dilation (TID) and transient right ventricular visualization (TRV), are recognized as markers of extensive CAD and predictive of adverse outcomes. They usually occur in association with stress-induced regional MPI abnormalities. However, the clinical significance of these ancillary markers in the presence of normal stress MPI is incompletely understood. METHODS: From a cohort of 564 consecutive patients referred for clinical SPECT stress MPI, 44 patients had normal stress SPECT MPI and either TID (n = 28) or TRV (n = 16). These imaging findings were correlated with CT coronary calcium (CAC), CT coronary angiography (CTA), and invasive coronary angiography (ICA) in patients with severe CAC ≥ 1000 HU. TID and TRV were quantified as stress/rest ratios. Severe CAD was defined as > 70% luminal stenosis on CTA or ICA. RESULTS: The median TID ratio was 1.23, with a range of 1.13-1.48; the median TRV ratio was 1.30, with a range of 1.20-1.48. Of 44 patients with TID or TRV, only 9 patients (20.5%) had severe obstructive > 70% CAD by angiography (6 of 28 patients (21.5%) with TID and 3 of 16 patients (19%) with TRV). Severe multi-vessel CAD occurred in only 2 of 44 patients (4.5%). In contrast, of 9 patients with CAC > 1000 HU, 6 (67%) had severe obstructive CAD. CONCLUSION: In patients with normal stress SPECT MPI and TID or TRV, the incidence of severe obstructive CAD was relatively low and predominantly single-vessel CAD. These findings do not support the concept that TID or TRV with normal stress MPI is predictive of high-risk CAD.

The effect of video-based educational program on satisfaction and comfort in patients undergoing transradial coronary angiography: A single-blinded, randomized controlled trial.

Cardiac catheterization has been the most widely used diagnostic method, and in most cases, invasive diagnostic methods are associated with stress and concern that can affect the satisfaction and comfort of patients undergoing transradial coronary angiography. In this randomized controlled trial, a total of 89 patients undergoing transradial coronary angiography were recruited using convenience sampling. Then, the patients were assigned to two groups of intervention and control using blocked randomization, as those in the intervention group received video-based patient education and those in the control group received no training. Data were collected using the Persian version of the patient satisfaction questionnaire and the visual analog scale. The variables were measured before, 2, 4, and 8 hours after the angiography. The results indicated that, after the intervention, the mean scores of satisfaction and comfort in the intervention group were higher than in the control group (P < .001). Video-based educational strategies should be integrated into the nursing interventions to improve patients' health status.

Very Early Discharge of Patients with ST-Segment-Elevation Myocardial Infarction after Primary Percutaneous Coronary Intervention.

Background: The discharge of uncomplicated patients with ST-segment-elevation myocardial infarction (STEMI) within 48 to 72 hours has been proven safe and feasible. The safety and feasibility of the very early discharge (≤48 h) of such patients, especially during the COVID-19 pandemic with limited bed availability and infection risk, have yet to be evaluated. Methods: In this cohort study on 108 patients with STEMI who presented to Farshchian Heart Center between February and May 2020, 30 patients received fibrinolysis and 78 were scheduled for emergent coronary angiography. One patient had no coronary obstruction, 3 underwent emergent surgery, and 3 had high-risk features mandating a prolonged stay. The remaining patients were assigned to either Group A (≤48 h) or Group B (>48 h) regarding hospital discharge. Demographic, angiographic, procedural, and outcome data were compared between the 2 groups. Results: Group A consisted of 51 patients, including 7 women (13.7%), at a mean age of 62.74±12.35 years, and Group B comprised 20 patients, including 4 women (20.0%), at a mean age of 65.20±12.82 years. The mean hospital length of stay was 38.02±9.15 hours in Group A and 88.20±23.31 hours in Group B (P<0.001). The mean stent diameter was smaller in Group B (3.19±0.34 mm vs 2.96±0.29 mm; P=0.008). Demographic, angiographic, procedural, and outcome data, including the rates of in-hospital, 1-week, and 1-month mortality, were similar between the 2 groups. Conclusion: This study shows that a hospital discharge in less than 48 hours in low-risk patients with STEMI is safe and feasible. The potential advantages of this approach in the COVID-19 pandemic should be balanced against its risks.

Randomized trial of intracoronary adenosine as adjunctive therapy for prevention of the no-reflow phenomenon.

No-reflow phenomenon as a serious complication following percutaneous coronary intervention, deteriorates clinical outcomes. Intracoronary (IC) Adenosine, seems to be a way to deal with it. One hundred four consecutive patients with ST-segment elevation myocardial infarction were randomized into two groups. Each group consisted of 52 patients who managed with two bolus doses of IC Adenosine (Adenosine group) or two bolus doses of IC normal saline (placebo group) administered before and after stenting. Thrombolysis in myocardial infarction (TIMI) grade flow, ST-segment resolution (STR) and post-procedural clinical outcomes were used as endpoints. IC adenosine led to lower rates of no-reflow based on TIMI grade flow scaling (15.4% vs. 44.3%; P-value: 0.02). STR classified as complete, partial and no resolution was similar between two groups (P-value: 0.748). Also, post-interventional clinical outcomes, including arrhythmia, left ventricular ejection fraction, hospitalization time, and 30 days mortality were similar between Adenosine and placebo groups.

An Evaluation of the Numbers and Locations of Coronary Artery Disease with Some of the Major Atherosclerotic Risk Factors in Patients with Coronary Artery Disease.

INTRODUCTION: Despite definite recognition of major atherosclerotic risk factors, the relationship between the pattern of coronary artery disease and these risk factors is unknown. AIM: The aim of this study was to identify the relationship between some of the major atherosclerotic risk factors and the number and pattern of coronary artery disease in patients with coronary artery disease who presented to Farshchian Heart University Hospital, Hamadan, Iran. MATERIALS AND METHODS: In this descriptive cross-sectional study, we investigated some of the major atherosclerotic risk factors and their relationships with the type of coronary artery disease in terms of number and location of disease. A total of 1100 patients were enrolled with coronary artery disease confirmed by selective coronary angiography from 2010-2014. A p-value<0.05 was considered statistically significant. RESULTS: A total of 1100 patients enrolled in this study. The patient population consisted of 743 (67.5%) males and 357 (32.5%) females. A meaningful relationship existed between ageing, diabetes mellitus, hypertension and 3-Vessel Disease (3VD, p<0.001) as well as between hyperlipidemia and Single Vessel Disease (SVD, p<0.001). Patients diagnosed with diabetes mellitus, hypertension, and hyperlipidemia showed greater potential to develop coronary artery disease at the proximal section of the coronary arteries. CONCLUSION: Based on the relationship between some of the major risk factors and the pattern of coronary artery disease in the current study, prospective studies should investigate other risk factors. We recommend that a plan should be developed to reduce adjustable risk factors such as diabetes mellitus, hypertension and hyperlipidemia in order to decrease coronary artery disease.

Evaluation of the Relationship between Serum 25-Hydroxy Vitamin D and Hypertension in Hamadan, Iran-A Case Control Study.

INTRODUCTION: Hypertension or high blood pressure is one of the main reasons of fatality in the world. The role of vitamin D in developing hypertension has not been proved yet. Some studies have shown positive correlation between low serum vitamin D level and hypertension. Due to this fact, recognising hypertension risk factors such as potential impact of low serum vitamin D level seems to be required. AIM: This study was conducted to evaluate potential impact of serum vitamin D level on hypertension. MATERIALS AND METHODS: This case-control study had 188 subjects including 55 cases suffering from hypertension and 133 controls with normal blood pressure in Hamadan, Iran. After taking the medical history and physical examination, 5 cc of their blood was taken to measure their serum 25-Hydroxyvitamin D [25(OH)D] level through ELISA test. Data analysis was done by version 16.0 of SPSS software and used independent sample t-test and Chi-square test for related comparisons. RESULTS: Mean and standard deviation of serum 25(OH)D level in patients suffering from hypertension was 13.10±9.7 ng/ml and in control group was 20.87±10.34 ng/ml. This variance was statistically significant (p<0.001). Mean serum 25(OH)D level in both case and control groups was measured after gender and age stratification. Mean serum 25(OH)D level in cases and controls was 13.12±11.4 ng/ml and 21.38±11.47 ng/ml in males (p=0.016) and 13.10±9.91 ng/ml and 19.19±10.55 ng/ml (p=0.004) in females, respectively. Mean serum 25(OH)D level in under 50-year-old was 10.82±8.73 ng/ml and 20.07±11.17 ng/ml in cases and controls respectively (p<0.001). In over 50-year-old, there was no significant relationship between mean serum 25(OH)D and blood pressure levels (p>0.05). CONCLUSION: According to this study, reverse relationship between serum 25(OH)D and blood pressure levels was seen.

Impact of stent type on incidence of major adverse cardiac events in large coronary arteries with tubular and diffuse lesions.

BACKGROUND: The aim of this study was to compare 3 year incidence of major adverse cardiac events (MACE) between bare metal stents (BMS) and drug-eluting stents (DES) in large coronary arteries with tubular and diffuse lesions. METHODS: Seven hundred forty-five consecutive patients (894 lesions) who underwent percutaneous coronary intervention (PCI) on large coronary arteries (3.0, 3.5 and 4 mm) with tubular (10-20 mm length) or diffuse (>20 mm) lesions using BMS or DES at Ekbatan University Hospital, Hamadan, Iran between October 2009 and September 2012 were included. Patients were divided into six groups based on the diameter and length of the stents: 3.0*≤20 mm, 3.0*>20 mm, 3.5*≤20 mm, 3.5*>20 mm, 4.0*≤20 mm and 4.0*>20 mm. Follow-up visits were set at 1, 2, and 3 years after the procedure. Endpoints of the study were MACE including cardiac death, nonfatal MI (due to in-stent thrombosis) and target lesion revascularization (TLR). RESULTS: Cardiac death occurred in 12 patients (1.7%), (1.8% in BMS vs. 1.2% in DES). The incidence of MACE was significantly higher in 3-mm coronary arteries with diffuse lesions (>20 mm) in BMS group; however, there were no statistically significant difference in the incidence of MACE following PCI with BMS and DES in 3, 3.5 and 4 mm coronary arteries with tubular lesions (≤20 mm) and 3.5 and 4 mm coronary arteries with diffuse lesions. CONCLUSIONS: Since the incidence of MACEs did not differ significantly between BMS and DES in most sizes, we suggested that PCI with BMS for coronary arteries in the mentioned sizes can be safe and effective. Further randomized clinical trials focusing simultaneously on diameter and the length of stents are required to corroborate this finding.

Plasma homocysteine level and its genotypes as a risk factor for coronary artery disease in patients undergoing coronary angiography.

BACKGROUND: Hyperhomocysteinemia has recently been identified as a risk factor for coronary artery disease. Some genetic variants (such as C677T polymorphism) are postulated in this regard. We studied the relation between hyperhomocysteinemia and the above genetic variant and risk of coronary artery disease (CAD) and also the number of involved vessels. MATERIALS AND METHODS: From a total of 90 patients, 45 showed angiographically documented CAD and 45 had clinical manifestations of CAD but a negative angiography. Blood homocysteine level and C677T polymorphism were evaluated by Enzyme-linked immunosorbent assay (ELISA) and polymerase chain reaction (PCR) respectively. RESULTS: Homocysteine level was significantly higher in the case group (P < 0.001) but no correlation was found between its level and extent of CAD. More homozygote cases of C677T allele were detected in the case group which was not related to the extent of CAD either. CONCLUSION: Presence of hyperhomocysteinemia increases the risk of CAD but does not predict the extent of it.