Fragmented QRS, a strong predictor of mortality and major arrhythmic events in patients with nonischemic cardiomyopathy: A systematic review and meta-analysis.

Background and Aims: Fragmented QRS (fQRS), which is associated with rhythm disturbances, can predispose the heart to fatal ventricular arrhythmias. Recently, accumulating studies indicates that fQRS is associated with poor prognosis in various types of cardiomyopathies. Therefore, we assessed the association between fQRS with all-cause mortality and major arrhythmic events (MAEs) in patients with nonischemic cardiomyopathy, in this systematic review and meta-analysis study. Methods: We performed a comprehensive search in databases of PubMed/Medline, EMBASE, and Web of Science from the beginning to December 31, 2022. Published observational studies (cohorts, case-control, or analytical cross-sectional studies) were included that report the prognostic value of fQRS in patients with different types of nonischemic cardiomyopathies for MAEs (sudden cardiac death, sudden cardiac arrest, sustained ventricular tachycardia [VT], ventricular fibrillation [VF], and appropriate shock) and all-cause mortality. We pooled risk ratios (RRs) through raw data and adjusted hazard ratios (aHRs) using "Comprehensive Meta-Analysis" software, Version 2.0. Results: Nineteen cohort and three analytical cross-sectional studies were included in this meta-analysis involving a total of 4318 subjects with nonischemic cardiomyopathy (1279 with fQRS and 3039 without fQRS). FQRS was significantly associated with an increased risk of all-cause mortality in patients with nonischemic cardiomyopathy (pooled RR: 1.920; 95% confidence interval [CI]: 1.388-2.656, p < 0.0001/pooled HR: 1.729; 95% CI: 1.327-2.251, p < 0.0001). Also, the risk of developing MAEs in the presence of fQRS was significantly increased (pooled RR: 2.041; 95% CI: 1.644-2.533, p < 0.0001/pooled HR: 3.626; 95% CI: 2.119-6.204, p < 0.0001). In the subgroup analysis, the strongest association between fQRS presence and increased MAEs was observed in patients with hypertrophic cardiomyopathy (HCM) (pooled RR: 3.44; 95% CI: 2.07-5.71, p < 0.0001/pooled HR: 3.21; 95% CI: 2.04-5.06, p < 0.0001). Conclusion: Fragmented QRS could be a prognostic marker for all-cause mortality and MAEs in patients with various types of nonischemic cardiomyopathies, particularly HCM.

The Association Between Hematologic Indices With TIMI Flow In STEMI Patients Who Undergo primary percutaneous coronary intervention.

BACKGROUND: The Primary Percutaneous Coronary Intervention (PPCI) is the preferred therapeutic strategy for patients who experienced ST-Elevation Myocardial Infarction (STEMI). OBJECTIVE: We aimed to evaluate the association of hematological indices, including hemoglobin level, platelets, White Blood Cells (WBCs) count, and MPV before PPCI with the TIMI grade flow after PPCI. METHODS: STEMI patients who experienced PPCI were included in the present retrospective crosssectional study. Then participants were divided into three groups based on their post-procedural TIMI flow grades. Demographic data and hematologic indices of patients before PPCI were collected and their association with the TIMI grade flow after PPCI was evaluated. To compare the quantitative and qualitative variables, chi-square and t-tests were performed, respectively. RESULTS: We found that elevated levels of hemoglobin and decreased levels of MPV had a significant association with an advanced grade of TIMI flow. Interestingly, in the normal range, there was a significant association between higher platelet count and TIMI-flow grade 1. Besides, TIMI flow grades 2 and 3 had a significant association with low and moderate platelets count, respectively. CONCLUSION: In conclusion, evaluating MPV, platelets, and hemoglobin levels before PPCI as easy and accessible parameters may be able to identify high-risk STEMI patients undergoing PPCI.

Correlation Between TIMI Risk Score and the Number of Vessels Involved in the Angiographic Study; a Cross-sectional Study.

Introduction: TIMI (Thrombolysis in Myocardial Infarction) score is a model for predicting the severity of vascular diseases. This study aimed to evaluate the correlation between this score and the number of vessels involved in patients with Unstable Angina (UA) or Non-ST Elevation Myocardial Infarction (NSTEMI). Methods: This prospective cross-sectional study was designed to evaluate the correlation between TIMI score, and the number of vessels involved in the angiographic study of NSTEMI and UA patients presenting to emergency department. Results: 297 patients with the mean age of 62.16±36.59 years were entered (58.2% male; 193 (65%) UA and 104 (35%) NSTEMI). The Mean TIMI score among patients was 3.21±1.55. Based on the TIMI score, patients were categorized into 3 groups. 105 (35.35%) patients had a TIMI score of 0 to 2, 120 (40.40%) had a score of 3 to 4, and 72 (24.24%) had a score of 5 to 7. Patients with a TIMI score of 5 to 7 had a greater likelihood of three-vessel coronary artery disease compared to patients with a TIMI score of 3 to 4 (OR: 5.34, 95% CI: 2.64 to 10.80; p < 0.0001) or those with a TIMI score of 0 to 2. (OR: 29.45, 95% CI: 12.87 to 67.37; p < 0.0001). Two-vessel coronary artery disease was more likely to be found in patients with a TIMI score of 3 to 4 or those with a score of 5 to 7 compared to patients with a TIMI score of 0 to 2 (OR: 3.69, 95% CI: 1.60 to 8.51; p <0.0001 and OR: 2.67, 95% CI: 1.04 to 6.82; p = 0.04, respectively). Conclusion: There is a direct and significant correlation between TIMI score and the number of coronary vessels involved in patients presenting to emergency department following UA or NSTEMI.

Coronary pseudoaneurysm 1 week after complex percutaneous coronary intervention with drug-eluting stent.

Pseudoaneurysm formation is a rare complication after complex PCI with drug-eluting stents. Cardiologists and interventionist should be familiar with this rare complication after PCI and its management options.

Double orifice mitral valve in a patient with bicuspid aortic valve and coarctation of the aorta: A rare presentation.

Double orifice mitral valve is a rare condition and may be accompanied by a bicuspid aortic valve (sometimes normal functioning) and coarctation of the aorta. Echocardiography is valuable in detecting the accompanied anomalies. Management depends on the severity of mitral valve function and the severity of associated anomalies.

One-Month Outcomes of Cases Receiving Ticagrelor after Percutaneous Coronary Intervention; a Case Series.

INTRODUCTION: Ticagrelor is the first reversibly binding oral P2Y12 receptor antagonist that can block ADP-induced platelet aggregation. This study aimed to describe one-month follow-up findings of cases undergoing ticagrelor therapy after percutaneous coronary intervention (PCI). METHODS: This case series was performed on acute coronary syndrome (ACS) patients who were candidates for PCI and received aspirin plus ticagrelor after PCI. Patients were followed for one month and their outcomes were described. RESULTS: 156 cases with the mean age of 59.74 ± 9.24 years were studied (63% male). 45 (28.8%) cases complained of dyspnea (39 cases with mild and 6 cases with severe dyspnea). Bleeding occurred in 4 (2.5%) cases (intra-cranial hemorrhage (ICH) in one, hematuria in two, and skin hemorrhage in one case). There were no cases with bradycardia or thrombosis. One (0.6%) patient developed drug hypersensitivity reaction, which manifested as skin rash. The use of drug was stopped in 10 (6.4%) cases due to severe dyspnea (n= 6), ICH (n=1), skin rash (n=1), and concomitant left ventricular (LV) clot (n=2). CONCLUSION: The most important finding of one-month ticagrelor consumption were dyspnea, bleeding, and hypersensitivity reaction. No case of bradycardia and stent thrombosis was detected. In our study , iranian population has more susceptibility to dyspnea than PLATO result. The rate of drug discontinuation in this series of cases was 6.4 %.

Value of Delta Fractional Flow Reserve (ΔFFR) For Predicting Coronary Ischemic Lesions.

BACKGROUND: The decrease in fractional flow reserve (FFR) after adenosine administration from baseline FFR value (termed as ΔFFR) may reflect the compensatory capacity of the microvascular circulation and thus may predict significant coronary stenotic lesions. We aimed to investigate whether baseline FFR and ΔFFR can help identify the coronary ischemic lesion and its severity. MATERIALS AND METHODS: This cross-sectional study was performed on 154 consecutive patients (Mean age 62.42 ± 9.36 years) that underwent coronary angiography and with definitive intermediate coronary lesions at any of the coronary vessels. FFR was calculated by dividing the mean distal intracoronary pressure by the mean arterial pressure. ΔFFR was also defined as the difference between baseline FFR and hyperemic FFR (considering FFR<0.75 as the criteria for ischemia). RESULTS: The area under receiver-operating characteristic curve for baseline FFR was found as 0.933, and for ΔFFR was 0.946 indicated high values of both indices for predicting ischemic lesions. The best cut-off point for baseline FFR and ΔFFR for discriminating ischemic lesions from the normal condition was 89.5 (yielding a sensitivity of 92.2% and a specificity of 68.0%) and 9.5 (yielding a sensitivity of 96.0% and a specificity of 85.3%), respectively. CONCLUSION: Our study could successfully demonstrate the high value of both baseline FFR and ΔFFR for predicting coronary ischemic lesions with the cut-off values of <89.5 and >9.5, respectively.

Is it necessary to discontinue metformin in diabetic patients with GFR > 60 ml/min per 1.73 m2 undergoing coronary angiography: A controversy still exists?

BACKGROUND: Although metformin is not directly nephrotoxic, it has been postulated that it can impair gluconeogenesis from lactate, which may lead lactate to be accumulated under circumstances such as contrast-induced nephropathy. The present study aims to assess the role of metformin in lactate production in a group of diabetic patients with GFR > 60 ml/min per 1.73 m2undergoing coronary angiography. METHODS: In the present randomized clinical trial, 162 metformin-treated diabetic patients were enrolled. The enlisted patients were scheduled to undergo coronary angiography at Modarres Hospital from Feb 2012 to Nov 2012. Patients were randomly allocated to continue metformin during peri-angiography period (M (+) group) or to stop the medication 24 hours prior the procedure (M (-) group). All the patients had glomerular filtration rate of >60 mL/min per 1.73 m2. Iodixanol was the only contrast media which in all patients. Metformin-associated lactic acidosis (MALA) was defined as an arterial pH <7.35 and plasma lactate concentration >5 mmol/L. RESULTS: 162 patients, including79 (48.7%) male and 83 (51.3%) female patients were enrolled in the study. The average of GFR was comparable in both groups (76 ml/min per 1.73 m2 in the M (+) group versus 79 ml/min per 1.73 m2 in the M (-) group, p=0.53). No significant difference was observed in the mean dose of metformin before the study between the 2 groups (2.18 tablets per day in M (+) group vs. 2.21 tablets per day in M(-) group, p=0.62).No lactic acidosis was observed in the studied groups. CONCLUSION: In conclusion, the results of the present study indicate that metformin continuation in diabetic patients with a GFR of more than 60 ml/min per 1.73 m2 undergoing coronary angiography does not enhance the risk of MALA development.

Left ventricular sphericity index analysis for the prediction of appropriate implantable cardioverter-defibrillator therapy.

BACKGROUND: Implantable cardioverter-defibrillator (ICD) is the most effective therapy currently available to prevent sudden cardiac death (SCD) in patients with left ventricular (LV) dysfunction. Although LV ejection fraction (LVEF) is an excellent marker of SCD in these patients, determining other predictors might help to identify patients who will be benefit more from device implantation. The purpose of this study was to determine whether abnormal LV sphericity index (SI) in transthoracic echocardiography is associated with appropriate ICD therapy in these patients. METHODS: A total of 140 patients with primary ICD implantation (mean age 62.59 ± 11.36 years; 98 [70%] male) were included. The patients were classified into "no ICD therapy" or "ICD therapy" group according to the information of their devices for a maximum of 2 previous years. In four-chamber view image of transthoracic echocardiography, SI was calculated by dividing the major-axis dimension to minor-axis dimension of LV in both groups. RESULTS: Compared with patients with no ICD therapy, patients in ICD therapy group had lower LVEF (31.36 ± 9.58 vs 23.24 ± 6.03, P = 0.0001) and lower SI (1.79 ± 0.29 vs 1.57 ± 0.32, P = 0.0001). In multivariant logistic regression analysis, the SI of ≤1.58 was associated with fourfold increase of appropriate ICD therapy, even after adjusting for LVEF (odds ratio, 4.08; 95% confidence interval, 1.71-9.75; P = 0.02). CONCLUSION: Simple echocardiographic sphericity dimension index as a marker of cardiac remodeling may be an important predictor of appropriate ICD therapy in patients with primary prevention ICDs and may provide additive risk stratification in patients with LV systolic dysfunction.

The association between exposure to air pollutants including PM10, PM2.5, ozone, carbon monoxide, sulfur dioxide, and nitrogen dioxide concentration and the relative risk of developing STEMI: A case-crossover design.

BACKGROUND: Unfavorable associations between air pollution and myocardial infarction are broadly investigated in recent studies and some of them revealed considerable associations; however, controversies exists between these investigations with regard to culprit components of air pollution and significance of correlation between myocardial infarction risk and air pollution. METHODS: The association between exposure to PM10, PM2.5, ozone, carbon monoxide, sulfur dioxide, and nitrogen dioxide concentration of background air that residents of Tehran, the capital city of Iran, which is ranked as the most air polluted city of Iran and the relative risk of developing ST-elevation myocardial infarction (STEMI) were investigated by a case-crossover design. Our study included 208 patients admitted with a diagnosis of STEMI and undergone primary percutaneous intervention. Air pollutant concentration was averaged in 24-h windows preceding the time of onset of myocardial infarction for the case period. Besides, the mean level of each element of air pollution of the corresponding time in one week, two weeks and three weeks before onset of myocardial infarction, was averaged separately for each day as one control periods. Thus, 624 control periods were included in our investigation such that. Each patient is matched and compared with him/herself. RESULTS: The mean level of PM10 in case periods (61.47µg/m3) was significantly higher than its level in control periods (57.86µg/m3) (P-value = 0.019, 95% CI: 1.002-1.018, RR = 1.010). Also, the mean level of PM2.5 in case periods (95.40µg/m3) was significantly higher than that in control days (90.88µg/m3) (P-value = 0.044, 95% CI: 1.001-1.011, RR = 1.006). The level of other components including NO2, SO2, CO and O3 showed no significant differences between case and control periods. A 10µg/m3 increase in PM10 and PM2.5 would result in 10.10% and 10.06% increase in STEMI event, respectively. Furthermore, the results of sub-group analysis showed that older patients (equal or more than 60 year-old), diabetic patients, non-hypertensive ones and patients with more than one diseased vessel may be more vulnerable to the harmful effect of particular matters including PM10 and PM2.5 on development of STEMI. CONCLUSION: Air pollution is a worldwide pandemic with great potential to cause terrible events especially cardiovascular ones. PM2.5 and PM10 are amongst ambient air pollutant with a high risk of developing STEMI. Thus, more restrictive legislations should be applied to define a safe level of indoor and outdoor air pollutant production.

Evaluation of pentraxin-3 level and its related factors in patients undergoing primary percutaneous coronary intervention.

BACKGROUND: Inflammation has an important role in the development and progression of atherosclerosis, and acute phase proteins such as pentraxin-3 (PTX3) can be deployed in determining the prognosis of coronary artery disease (CAD). So the purpose of this paper was to evaluate the PTX3 level and its related factors in patients undergoing primary percutaneous coronary intervention (PCI). METHODS: In this cross-sectional study, the PTX3 levels were determined for 100 patients with ST-elevation myocardial infarction referred to the Modarres Hospital, Tehran, Iran. Checklist included demographic data [age, gender, history of myocardial infarction (MI)] and characteristics of heart disease (type of MI, culprit, and pre-dilation). PTX3 was measured for all patients before PCI. RESULTS: In this study, the mean age of the participants was 58.7 (11.4). Global registry of acute coronary events (GRACE) score was higher in the group with abnormal PTX3 levels (P = 0.008). The number of the involved vessels (P = 0.005), MI type (P = 0.05), and the need for PCI all had a significant relation with abnormal PTX3 levels. The increased levels of PTX3 received higher Killip class, lower ejection fraction, and higher GRACE score. The group with abnormal PTX3 had a significant difference in platelet counts (P = 0.018) in comparison with the group with normal level of PTX3. CONCLUSION: Currently, the biomarkers are highly important in the field of cardiovascular diseases. The diagnostic and prognostic importance of PTX3 as a new marker has been underscored in recent studies. Differentiating between high-risk patients with acute cardiac infarction and low-risk ones through their clinical signs is difficult.

A Novel Risk Score in Predicting Failure or Success for Antegrade Approach to Percutaneous Coronary Intervention of Chronic Total Occlusion: Antegrade CTO Score.

Total occlusion of a coronary artery for more than 3 months is defined as chronic total occlusion (CTO). The goal of this study was to develop a risk score in predicting failure or success during attempted percutaneous coronary intervention (PCI) of CTO lesions using antegrade approach. This study was based on retrospective analyses of clinical and angiographic characteristics of CTO lesions that were assessed between February 2012 and February 2014. Success rate was defined as passing through occlusion with successful stent deployment using an antegrade approach. A total of 188 patients were studied. Mean ± SD age was 59 ± 9 years. Failure rate was 33%. In a stepwise multivariate regression analysis, bridging collaterals (OR = 6.7, CI = 1.97-23.17, score = 2), absence of stump (OR = 5.8, CI = 1.95-17.9, score = 2), presence of calcification (OR = 3.21, CI = 1.46-7.07, score = 1), presence of bending (OR = 2.8, CI = 1.28-6.10, score = 1), presence of near side branch (OR = 2.7, CI = 1.08-6.57, score = 1), and absence of retrograde filling (OR = 2.5, CI = 1.03-6.17, score = 1) were independent predictors of PCI failure. A score of 7 or more was associated with 100% failure rate whereas a score of 2 or less was associated with over 80% success rate. Most factors associated with failure of CTO-PCI are related to lesion characteristics. A new risk score (range 0-8) is developed to predict CTO-PCI success or failure rate during antegrade approach as a guide before attempting PCI of CTO lesions.

Successful Angioplasty of Left Vertebral Artery and Right Subclavian Artery Via Retrograde Approach.

We describe a 77-year-old male who had right upper limb ischemic symptoms and history of unsuccessful right subclavian artery angioplasty. According to ultrasound findings, upper limb angiography was performed which confirmed stenosis of the left vertebral and right subclavian arteries. Percutaneous angioplasty and stenting of left vertebral and right subclavian arteries were performed in two separate sessions. Retrograde approach was scheduled for right subclavian artery angioplasty which is challenging due to potential risks to adjacent vertebral artery. This case reports underscores that percutaneous approaches may be preferential given their confirmed long-term efficacy and lower morbidity.

Upper extremity deep venous thrombosis and stenosis after implantation of pacemakers and defibrillators; A prospective study.

BACKGROUND: Obstruction of the access vein following cardiac pacemaker and defibrillator implantation is a common complication. However, the exact incidence and contributing risk factors are unknown. The aim of this study is to determine the incidence and analyze the contribution of each risk factor. METHODS: 57 consecutive patients candidate for their first transvenous pacemaker, implantable cardioverter-defibrillator (ICD), or cardiac resynchronization therapy device implantation were enrolled. After implantation, venography of the ipsilateral peripheral arm was performed. Patients underwent their second venography after the follow-up period of 3 to 6 months. RESULTS: 42 patients (13 females, mean age 59.71 ± 12.33) completed the study. The followup venography showed significant venous obstruction (more than 50%) in 9 (21%) patients, but in none of the individuals, venography revealed total occlusion of the veins. Patients with obstruction had more leads in their veins (2.56 ± 0.53 vs 1.58 ± 0.71, P = 0.001). Venous obstruction was significantly more prevalent in patients with implanted cardiac resynchronization therapy device compared with an ICD or pacemaker (p = 0. 01). Age, gender, diabetes mellitus, hypertension, ischemic heart disease and antiplatelet consumption did not reveal any other contribution to the risk of thrombosis. In multivariate analysis, total lead number was a positive predictor for venous occlusion (P = 0.015, OR:19.2, and CI: 1.7-207.1). CONCLUSION: Venous obstruction is relatively frequent after pacemaker or ICD implantation. This study also shows that pacemaker and ICD leads have a similar risk for lead-related venous obstruction. However, patients with multiple leads are associated with an increased risk.

The Safety of Using Large Amount (30 cc) of Onyx (Ethylene-vinyl Alcohol Copolymer) for the Treatment of Large Type II Endoleak after Endovascular Repair of Abdominal Aortic Aneurysm.

Endovascular aneurysm repair (EVAR) is associated with late complications including the development of endoleaks as major complications. Type II endoleak is the consequence of collateral retrograde flow from the aortic branches; generally from the lumbar arteries, inferior mesenteric artery, or middle sacral artery. The method and the ideal timing for the treatment of endoleaks remain controversial. We are presenting a case of successful treatment of a large type II endoleak using embolization with large amount of Onyx copolymer via a percutaneous transfemoral route without any adverse outcome. A significant advantage of Onyx as opposed to glue is that it may be injected for a long period of time (20-60 minutes) with a lower risk for microcatheter entrapment. This case report suggests that much higher amount of Onyx can safely be used if needed to seal large endoleaks without adverse event.

Visual-Functional Mismatch Between Coronary Angiography, Fractional Flow Reserve, and Quantitative Coronary Angiography.

Anatomical and functional mismatches are not uncommon in the assessment of coronary lesions. The aim of this study was to identify clinical and lesion-specific factors affecting angiographic, anatomical, and functional mismatch in intermediate coronary lesions. In patients who underwent coronary angiography for clinical reasons, fractional flow reserve (FFR), and quantitative coronary angiography (QCA) analyses for intermediate stenotic lesions were performed simultaneously. Mismatches between the measured values were analyzed. A total of 95 intermediate lesions were assessed simultaneously by visual angiography, FFR, and QCA. The visual-FFR mismatch was found in 40% of the lesions while reverse visual-FFR mismatch was determined in nearly 14% of the lesions. Mismatch and reverse mismatch between FFR and QCA parameters were observed in 10 and 23% of the lesions. FFR value was significant in 32% of the lesions while visually significant stenosis was shown in 61% of the lesions. Among the visual-FFR reverse mismatch group, the prevalence of culprit lesions within the left anterior descending (LAD) was significantly higher than other vessels (p value < 0.02). There were high frequencies of angiographic, QCA, and functional mismatches in analyses of intermediate coronary lesions. LAD lesions showed the highest mismatch. Angiographic or QCA estimation of lesion severity has consistently resulted in inappropriate stenting of functionally nonsignificant lesions or undertreatment of significant lesions based on FFR.

Comparison of fractional flow reserve measurements using intracoronary adenosine versus intracoronary sodium nitroprusside infusions in moderately stenotic coronary artery lesions.

INTRODUCTION: The aim of this study was to investigate the efficacy and safety of intracoronary (IC) sodium nitroprusside infusion in comparison to IC adenosine for fractional flow reserve (FFR) measurement in moderately diseased coronary artery lesions for functional assessment. METHODS: During a nine month period, a consecutive of 98 patients with suspected or known coronary artery disease with moderate stenosis found during angiography (40% to 70% stenosis), were enrolled in this study. Hyperemia was induced by bolus doses of IC adenosine followed by sodium nitroprusside for FFR measurement. RESULTS: Both IC adenosine and IC sodium nitroprusside induced similar and significant reduction in FFR. There was no statistically difference in FFR values between adenosine vs sodium nitroprusside infusions (mean FFR 84.3±6.3 vs 85.7±6.2, p=0.1) respectively. Furthermore, comparing different FFR cut-off points between the groups (FFR<0.75, 0.75-0.8 and >0.8) showed no significant differences (p value=0.7). CONCLUSION: An IC bolus of sodium nitroprusside (0.6µg/kg) infusion induces a similar degree of hyperemia to IC bolus of 100-300µg of adenosine. Therefore, IC sodium nitroprusside could be considered as an alternative drug to adenosine for FFR measurement with lower side effect profile.

The non-hyperemic coronary pressure notch as an indicator of the physiologic significance of coronary artery stenosis.

Myocardial fractional flow reserve (FFR) is a new index of the functional significance of intermediate coronary stenoses that is calculated from pressure measurements made during coronary arteriography. The aim of this study was to evaluate the correlation between non-hyperemic coronary pressure dicrotic notch and fractional flow reserve (FFR). A consecutive of 114 patients (73 men and 41 women) was enrolled in this study. Data were shown as means ± SD. Statistical analyses were performed with SPSS software. The statistical significance of differences was determined by chi-square analysis with Yates correction. Significance was defined as P< 0.05. Positive dicrortic notch was observed in 97 patients (85%). Significant association was detected between coronary pressure notch (dicrotic notch), and FFR as loss of the dicrotic notch was detected in 93.8% (15/16) of patients with FFR less than 0.75 (P=0.001). Upon ROC curve, a cutoff FFR value of approximately 0.75 demonstrated sensivity and specifity of 93.8% and 98%, respectively for loss of the dicrotic notch. The positive predictive value for loss of the dicrotic notch was 88.2%. Our study demonstrated loss of non-hyperemic coronary pressure diacrotic notch correlates significantly with FFR and may predict an FFR < 0.75 with high accuracy. In patients with functionally significant coronary stenosis, loss of non-hyperemic diacrotic notch appears to be a useful index of the functional severity of the stenoses and the need for coronary revascularization.

Resistant hypertension due to unilateral renal artery occlusion as the first presentation of antiphospholipid syndrome.

Resistant hypertension in the setting of renal artery occlusion should prompt further investigation for secondary causes in a young patient. We present renal artery occlusion in the setting of antiphospholipid syndrome as the initial presentation successfully treated with percutaneous intervention. This case is followed by review of the literature.

Cardiac failure as an unusual presentation in a patient with history of amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is the most well-known form of motor neuron diseases in which both upper and lower motor neurons are involved in this disease. We presented an unusual case of ALS whom had presented with chief complaint of dyspnea. Cardiac failure was diagnosed at the final stage of the ALS disease. The pathogenetic mechanism leading to an elevated occurrence of cardiomyopathy in ALS is not comprehensible. Dilated cardiomyopathy has been explained in some previous studies. Based on the collected data, it was hypothesized that cardiomyopathy is underdiagnosed in the ALS population, probably because symptoms are masqueraded as a result of the patients' disability. It was suggested that in all motor neuron diseases a serial cardiological evaluation should be executed, including annual echocardiography.