Determinants of Left Ventricular Systolic Function One Year after Primary Percutaneous Coronary Intervention for ST-elevation Myocardial Infarction in a Middle-Income Country.

BACKGROUND: Little is known about the predictors of left ventricular ejection fraction (LVEF) -an important predictor of mortality- after primary percutaneous coronary intervention (PCI) in low- and middle-income countries. METHODS: In a prospective cohort study at Imam Ali hospital, Kermanshah, Iran, we enrolled consecutive ST-elevation myocardial infarction (STEMI) patients treated with primary PCI (2016-2018) and followed them up to one year. LVEF levels were measured by echocardiography, at baseline and one-year follow-up. Determinants of preserved/improved LVEF were assessed using multi-variable logistic regression models. RESULTS: Of 803 patients (mean age 58.53±11.7 years, 20.5% women), baseline LVEF levels of ≤35% were reported in 44%, 35- 50% in 40%, and ≥50% in 16% of patients. The mean ± SD of LVEF increased from 38.13%±9.2% at baseline to 41.49%±9.5% at follow-up. LVEF was preserved/improved in 629 (78.3%) patients. Adjusted ORs (95% CIs) for predictors of preserved/improved LVEF showed positive associations with creatinine clearance, 1.01 (1.00-1.02) and adherence to clopidogrel, 2.01 (1.33-3.02); and inverse associations with history of myocardial infarction (MI), 0.44 (0.25-0.78); creatine kinase MB (CK-MB), 0.997 (0.996- 0.999); door-balloon time (3rd vs. 1st tertile), 0.62 (0.39-0.98); number of diseased vessels (2 and 3 vs. 1: 0.63 (0.41-0.99) and 0.58 (0.36-0.93), respectively); and baseline LVEF (35-50% and ≥50% vs. ≤35%: 0.45 (0.28-0.71) and 0.19 (0.11-0.34), respectively). CONCLUSION: Adherence to clopidogrel, short door-balloon time, high creatinine clearance, and lower baseline LVEF were associated with preserved/improved LVEF, while history of MI, high CK-MB, and multi-vessel disease were predictors of reduced LVEF. Long-term drug adherence should be considered for LVEF improvement in low- and middle-income countries.

Hypertension medication from guidelines to practice: A cohort study in western Iran.

PURPOSE: Hypertension (HTN) is one of the most common risk factors for non-communicable chronic diseases. The aim of the current study is to evaluate the prescribing patterns of antihypertensive medications in Kermanshah Province, west of Iran. METHODS: The Ravansar Non-Communicable Diseases (RaNCD) cohort study is the first Kurdish community-based study; subjects' age ranged from 35 to 65 years. In order to examine the use of medications to control blood pressure, participants were asked to bring all prescribed medications to the study center. Treatments were compared with 2013 European Society of Hypertension (ESH)/European Society of Cardiology (ESC) Guidelines for the management of arterial HTN. RESULTS: From a total of 10 040 participants in RaNCD cohort, 1575 (15.7%) individuals were hypertensive, of whom, 1271 (80.7%) people were aware of their condition. From 1153 (73.20%) people under treatment, 840 (72.8%) had their HTN properly controlled. The most common medications used to treat HTN were losartan (27.5%), metoprolol (14.3%), and captopril (11.9%). Regardless of type of treatment, 49.3% of all patients have received the medication for l 6 ≥ years. The most commonly used drugs were ß-blockers and angiotension receptor blockers as 620 (31.0%) and 612 (30.6%), respectively. Multivariable analysis showed that female gender, those receive ≥3 antihypertensive agents, and using preferred combinations were associated with a better blood pressure control. In addition, the probability of hypertension control was less likely with increasing duration of treatment (i.e >6 years) and in obese patients with ≥35 kg/m2 . CONCLUSIONS: Even though adherence to the international guidelines was acceptable, improvements can be made for better control of HTN. Therefore, it is imperative to educate healthcare professionals on improving their selection of antihypertensive medications and combination therapy for hypertensive patients.

Evaluation of Crocin Effect on Contrast-Induced Nephropathy Following Coronary Angiography or Angioplasty: A Randomized Controlled Trial.

Contrast-induced nephropathy (CIN) is the third cause of hospital-acquired acute kidney injury. The CIN prophylactic strategies adopted to date, although not highly efficient, are mostly based on antioxidant activity and hydration therapy. This study was designed and conducted to evaluate crocin's efficacy in the prevention of CIN in chronic kidney disease (CKD) patients undergoing coronary angiography/angioplasty. In this randomized clinical trial, a total of 110 eligible CKD stage 3 patients requiring contrast agent administration for coronary angiography/angioplasty were enrolled and randomly assigned to either crocin (n = 57) or control (n = 53) group. The patients in both groups received standard hydration therapy; nevertheless, in the crocin group, the patients were also orally administered three consecutive oral doses of 30 mg crocin tablets 1 day before up to 1 day after contrast media (CM) exposure. The primary endpoint was CIN incidence defined as an increase in serum creatinine (SrCr) level by ≥ 0.3 mg/dL or any change in urinary neutrophil gelatinase-associated lipocalin (NGAL) from the baseline within 48 hours of CM exposure. During 4 months, 130 patients were recruited. The mean age of the patients was 65.62 ± 9.05 years, and the majority of them were male (64.54%). The SrCr in the crocin group did not significantly increase within 48 hours of angiography/angioplasty. The changes in the urinary NGAL level were not significant in both groups. The CIN incidence was significantly lower in the crocin group than in the control group (1.75% and 13.2%; P = 0.028). Crocin administration plays an important nephron-protective role in the prevention of CIN.

Antimicrobial safety considerations in critically ill patients: part II: focused on anti-microbial toxicities.

INTRODUCTION: Antibiotic prescription is a challenging issue in critical care settings. Different pharmacokinetic and pharmacodynamic properties, polypharmacy, drug interactions, and high incidence of multidrug-resistant microorganisms in this population can influence the selection, safety, and efficacy of prescribed antibiotics. AREAS COVERED: In the current article we searched PubMed, Scopus and Google Scholar for neurotoxicities, hematologic toxicity and fluid stewardship in intensive care units. EXPERT OPINION: Critically ill patients who receive antimicrobial agents should be monitored for neurological, hematologic toxicities especially seizure, thrombocytopenia, and clostridioides infections. Other toxicities including QTc prolongation, electrolyte disturbances, liver enzyme elevation, and infusion-related reactions were being considered. Other changes, including fluid overload, hypoalbuminemia, augmented renal clearance, increased cardiac outputs in septic shock, and acute kidney injury, may influence treatment efficiency and patient outcome.

Antimicrobial safety considerations in critically ill patients: part I: focused on acute kidney injury.

INTRODUCTION: Antibiotic prescription is a challenging issue in critical care settings. Different pharmacokinetic and pharmacodynamic properties, polypharmacy, drug interactions, and high incidence of multidrug-resistant microorganisms in this population can influence the selection, safety, and efficacy of prescribed antibiotics. AREAS COVERED: In the current article, we searched PubMed, Scopus, and Google Scholar for estimating renal function in acute kidney injury, nephrotoxicity of commonly used antibiotics, and nephrotoxin stewardship in intensive care units. EXPERT OPINION: Early estimation of kidney function with an accurate method may be helpful to optimize antimicrobial treatment in critically ill patients. Different antibiotic dosing regimens may be required for patients with acute kidney injury. In many low-resource settings, therapeutic drug monitoring is not available for antibiotics. Acute kidney injury may influence treatment effectiveness and patient outcome.

Remdesivir-Associated Significant Bradycardia: A Report of Three Cases.

Recently, remdesivir was approved by the United States Food and Drug Administration for patients with Coronavirus disease 2019 (COVID-19). We herein describe 3 patients with COVID-19 who showed significant bradycardia and QTc prolongation after remdesivir administration. Bradycardia did not respond to atropine treatment in 2 of the patients, one of whom received theophylline and the other required a temporary pacemaker. Fortunately, the patients' heart rate and rhythm returned to normal after the discontinuation of remdesivir, albeit it lengthened their hospital stays. Careful monitoring during remdesivir infusion may decrease the risk of adverse cardiovascular side effects.

Analysis of QTc Interval during Levofloxacin Prescription in Cardiac Patients with Pneumonia.

BACKGROUND: Medications induced QT prolongation could cause ventricular arrhythmia, torsade de pointes, and death. OBJECTIVE: The purpose of this study was to evaluate the magnitude of QTc interval prolongation as a result of levofloxacin treatment in patients admitted to cardiology wards. METHODS: This was a cross-sectional study conducted in the coronary care units and general wards of the Imam Ali Heart Hospital in Kermanshah, Iran. The QTc interval was determined at baseline and after 72 hours of levofloxacin administration. Changes in the QTc interval before and after the levofloxacin prescription were determined. RESULTS: The mean age of recruited patients was 63.26 ± 14.56 years. More than 80% of patients who received levofloxacin experienced QTc prolongation. The QTc interval was increased significantly after levofloxacin administration (15.68 ± 26.84 milliseconds) (p<0.001). These changes remained significant after excluding medications with QTc lengthening properties (p<0.001). CONCLUSION: Treatment with levofloxacin in patients with heart disease increases the risk of QT prolongation.

Meropenem/colistin versus meropenem/ampicillin-sulbactam in the treatment of carbapenem-resistant pneumonia.

AIM: Efficacy of colistin and ampicillin-sulbactam have not been compared in treatment of ventilator-associated pneumonia due to A. baumannii. Efficacy of colistin and ampicillin-sulbactam in combination with meropenem were compared in treatment of ventilator-associated pneumonia due to carbapenem-resistant A. baumannii. METHOD: 47 patients with ventilator-associated pneumonia due to carbapenem-resistant A. baumannii were randomized to receive meropenem/colistin or meropenem/ampicillin-sulbactam for 14 days. Clinical and microbiological responses and 28-day mortality were considered as outcomes. RESULTS: Clinical response (75 vs 69.6%; p = 0.75) and microbial eradication (87.50 vs 91.3%; p = 0.59) were comparable between meropenem/colistin and meropenem/ampicillin-sulbactam groups, respectively. CONCLUSION: In this study, clinical and microbiological response were comparable between the meropenem/colistin and meropenem/ampicillin-sulbactam groups.

Antibiotic stewardship program in Intensive Care Unit: First report from Iran.

INTRODUCTION: Few data regarding antibiotic stewardship programs in critically ill patients are available. In the present study, the consequence of changing an empirical antibiotic regimen from a carbapenem (meropenem) to a noncarbapenem antibiotic (piperacillin-tazobactam) was evaluated in critically ill patients with a suspicion of sepsis. METHODS: This open-label randomized clinical trial was conducted during May 2015-January 2017 at the general Intensive Care Unit of the Imam Khomeini Hospital Complex, Tehran, Iran. In this study, a carbapenem (meropenem) or a noncarbapenem (piperacillin-tazobactam) antibiotic was considered as an empirical antibiotic regimen in 100 critically ill patients with a suspicion of sepsis. Clinical response and bacterial eradication were defined as primary and secondary outcomes of the study, respectively. Chi-square, Mann-Whitney, and independent sample t-tests were used for comparing variables between the groups. ANOVA was used to compare changes in the mean differences of parameters between the groups. Meaningful difference was indicated as P ≤ 0.05. RESULTS: During the first 72 h of the antibiotic course, the number of patients with clinical response was comparable between piperacillin-tazobactam and meropenem groups (21 [42%] and 25 [50%], respectively, P = 0.31). Also, at this time, microbial eradication occurred in 13 (54.16%) and 9 (40.90%) patients in piperacillin-tazobactam and meropenem groups, respectively (P = 0.67). CONCLUSIONS: Using a carbapenem (meropenem) instead of a noncarbapenem (piperacillin-tazobactam) as an empirical antibiotic regimen did not affect clinical response and bacterial eradication rates in critically ill patients with a suspicion of sepsis.

Clinical Response and Outcome in Patients with Multidrug Resistant Gram-negative Infections.

OBJECTIVE: In this study, frequency and antimicrobial sensitivity pattern of multidrug resistant (MDR) microorganisms were evaluated in a referral teaching hospital in Iran. METHODS: Patients with MDR Gram-negative pathogens were followed during the course of hospitalization. Demographic data, baseline diseases, type of biological sample, isolated microorganism, type of infection, antibiotic regimen before the availability of the culture result and change in the antibiotic regimen following receiving the antibiogram results, response to the treatment regimen, and duration of hospitalization and patient's outcome were considered variables for each recruited patient. FINDINGS: In 71% of the patients, antibiotic regimens were changed according to the antibiogram results. A carbapenem alone or plus amikacin or ciprofloxacin were selected regimens for patients with extended-spectrum beta-lactamase (ESBL) infections. For patients with probable carbapenem-resistant Enterobacteriaceae infections, a carbapenem plus colistin was the most common antibiotic regimen. Clinical response was detected in 54.5% of the patients who were treated based on the antibiogram results. Clinical response was higher in the ESBL producers (ESBL-P) than the non-ESBL-P infections (75% vs. 52%). However, this difference was not significant (P = 0.09). Most nonresponders (80%) had sepsis due to Klebsiella species. Finally, 41.9% of the patients were discharged from the hospital and 58.2% died. CONCLUSION: Same as other countries, infections due MDR microorganisms is increasing in the recent years. This type of resistance caused poor clinical response and high rate mortality in the patients.

Clinical response and outcome of pneumonia due to multi-drug resistant Acinetobacter baumannii in critically ill patients.

BACKGROUND AND OBJECTIVES: The frequency of multi-drug resistant Acinetobacter spp. infections is increasing in Iran. Considering availability of limited therapeutic options, clinical response and outcome of ventilator-associated pneumonia due to multi-drug resistant A.baumannii were evaluated in critically ill patients. MATERIALS AND METHODS: In this prospective study, 29 patients with carbapenem resistance A. baumannii ventilator-associated pneumonia were enrolled. Endotracheal aspirate specimens were analyzed according to the clinical and laboratory standard institute instructions in the hospital's microbiology laboratory. Demographics, clinical, microbiological and laboratory findings were collected for each patient during the treatment course. Therapeutic empirical regimen, change in antibiotic regimen following receiving antibiogram results, clinical and microbiological responses, duration of ICU stay and outcome were collected for each recruited individual. RESULTS: All of A. baumanii isolates were resistant to pipracillin-tazobactam, ceftriaxon, amikacin and ciprofloxacin. The resistance rate of A. baumanii species was 41.4% for ampicillin/sulbactabm and 93.1% for meropenem. Patients received either meropenem/colistin (51.7%) or meropenem/ampicillin-sulbactam (48.3%) as the treatment regimens based on the antimicrobial susceptibility patterns of isolates. Ventilator-associated pneumonia clinical response, improvement and failure achieved in 15 (51.7%), 8 (27.6%) and 6 (20.7%) of the patients respectively. Microbiological eradication and intermediate status were observed in 9/29 (31%) and 11/29 (37.9%) of patients, respectively. CONCLUSION: The antibiotic regimens showed comparable efficacy in treatment of VAP due to MDR A. baumannii but mortality rate was high. Considering widespread and high mortality rates associated with MDR infections, applying infection control and antibiotic stewardship programs in hospitals are essential.