Low Dose Spironolactone Monotherapy in the Management of Stage I Essential Hypertension: A Pilot Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: High blood pressure (BP) is a common chronic disease needs long life drug consumption to control. Spironolactone could be used as the fourth-line therapy in patients with resistant hypertension. However, there is no study to determine the effects of low dose spironolactone as a first line therapy in treatment of essential hypertension. The aim of this study is to investigate the effect of low dose spironolactone monotherapy in management of essential hypertension. METHODS: In this double blind randomized clinical trial, 40 patients who had stage I essential hypertension were randomly divided into two groups: intervention group received spironolactone 25 milligram once daily for one month and control group received placebo once daily. At the baseline and after one month, 24-hour BP holter-monitoring and serum potassium assay were done. RESULTS: Systolic BP was reduced from 143.5 ± 8.2 mmHg to 137.10 ± 7.57 mmHg in the intervention group, while it did not change significantly in control (between group treatment difference = -4.5 mmHg, p = 0.004). There was no significant reduction of diastolic BP in the intervention group in comparison to placebo group (between group treatment difference = -1.3 mmHg, p = 0.099). CONCLUSIONS: Short course monotherapy with low dose spironolactone is effective in reducing systolic BP in patients with stage I essential hypertension.

Comparison of medical treatments in cryptogenic stroke patients with patent foramen ovale: A randomized clinical trial.

BACKGROUND: This randomized clinical trial compared rates of stroke or transient ischemic attack recurrence or death in patients with cryptogenic stroke and patent foramen ovale (PFO) who received medical treatment with aspirin or warfarin. MATERIALS AND METHODS: Forty-four Iranian patients with cryptogenic stroke and patent foramen ovale participated in this randomized, single-blind trial between July 2007 and June 2010. All patients underwent transesophageal echocardiography and contrast-transcranial Doppler sonography to confirm the presence of patent foramen ovale. The patients were randomly assigned to receive aspirin or warfarin and were followed for 18 months for the recurrence of ischemic events or death. The principal investigator was blind to the group assignment. This trial is registered under number IRCT138805192323N1. RESULTS: Five (11.4%) patients had a stroke, 2 (4.5%) had a transient ischemic attack and 2 (4.5%) died. There was no difference in the rate of ischemic events or death between the aspirin- and warfarin-treated groups (hazard ratio: 0.45; 95% CI: 0.1-1.8; P = 0.259). CONCLUSION: There was no difference in ischemic event recurrence, death rates or side-effects between patients with cryptogenic stroke and patent foramen ovale who were treated with aspirin vs. warfarin.

Microembolic signals in patients with cryptogenic stroke with or without patent foramen ovale.

BACKGROUND: To evaluate the incidence, frequency, and contributing factors of microembolic signals (MESs) in patients with cryptogenic stroke with or without patent foramen ovale (PFO). METHODS: Transcranial Doppler monitoring for MESs detection was performed for 62 patients with acute cryptogenic stroke with PFO (PFO(+)) and 34 patients with acute cryptogenic stroke without PFO (PFO(-)). RESULTS: The incidence of MESs was not significantly higher in PFO(+) patients (17/62, 27.4%) in comparison to PFO(-) patients (6/34, 17.6%; odds ratio 1.76, 95% confidence interval 0.62-5.00; P = .327). The frequency of MESs in PFO(+) patients was statistically higher than that of PFO(-) patients (0.70 ± 1.47 v 0.23 ± 0.55; P = .026). MESs was presented with higher incidence in a subgroup of patients suffering from both patent foramen ovale and atrial septal aneurysm (P = .044). CONCLUSIONS: The likelihood of PFO as a source of MESs is higher when associated with atrial septal aneurysm.

Comparison of agitated saline mixed with blood to agitated saline alone in detecting right-to-left shunt during contrast- transcranial Doppler sonography examination.

PURPOSE: To evaluate a technique for contrast agent preparation as mixing the patients' blood with agitated saline and to compare it with agitated saline alone in diagnosis of cardiac right-to-left shunt in regard to their sensitivity, time window, and distribution of artificially induced microembolic signals. METHODS: Fifty-two patients with stroke who had Transesophageal echocardiography proven right-to-left shunt underwent contrast-transcranial Doppler sonography with injection of agitated (i) 9 ml saline with 1 ml air with Valsalva maneuver, (ii) 9 ml saline with 1 ml air without Valsalva maneuver, (iii) 8 ml saline, 1 ml of the patient's fresh blood and 1 ml air with Valsalva maneuver, and (iv) 8 ml saline, 1 ml of the patient's fresh blood and 1 ml air without Valsalva maneuver. RESULTS: The sensitivity of the bilateral middle cerebral artery monitoring in diagnosis of right-to-left shunt was 94.2%, 71.2%, 96.2% and 76.9% for agitated saline with Valsalva maneuver, agitated saline without Valsalva maneuver, agitated saline and blood with Valsalva maneuver, and agitated saline and blood without Valsalva maneuver methods, respectively. Severe right-to-left shunt was detected in 100% of patients when agitated saline and blood with Valsalva maneuver was used. Application of Valsalva maneuver resulted in detection of more right-to-left shunt (P = 0.002). CONCLUSION: Agitated saline mixed with blood with Valsalva maneuver is a sensitive method to detect right-to- left shunt, especially in the case of severe shunt. Mixing agitated saline with blood may increase the sensitivity of the test.

Balloon-shaped cystic subaortic membrane.

A 22-year-old man with a 4 month history of dyspnoea on exertion was referred for echocardiography. Transthoracic echocardiography revealed a balloon-shaped cystic mass (2 x 2 cm) attached to the left ventricular outflow tract (LVOT). Continuous-wave Doppler echocardiography showed a 44 mmHg mean LVOT gradient. The patient underwent transoesophageal echocardiography for detailed echocardiographic examination of LVOT and aortic valve. Transoesophageal echocardiography revealed a balloon-shaped cystic mass originating from the LVOT at the aorto-mitral communication. In the operating theatre, a cystic ballooning subaortic membrane was found and excised successfully. The morphology of the membrane was similar to that shown by transoesophageal echocardiography.

Patent foramen ovale in patients with tension headache: is it as common as in migraineurs? An age- and sex-matched comparative study.

The association of patent foramen ovale (PFO) and atrial septal aneurysm (ASA) with migraine headache attack (MHA) has been clearly shown. The same findings have been recently demonstrated also in cluster headache. Although tension-type headaches (TTH) are the most common kind of headache, their association with these atrial septal abnormalities has never been studied before. The study was conducted to clarify whether there was a significant association between the presence of such atrial septal abnormalities and tension headache, when compared with migraineurs. One hundred consecutive patients with migraine and 100 age- and sex-matched subjects with TTH and 50 healthy volunteers with no headache were enrolled in the study and underwent a complete transesophageal echocardiographic study with contrast injections at rest and with the Valsalva maneuver. There was no significant difference between the age and the sex of the participants of the three groups. The overall prevalence of PFO was 23% in patients with TTH and that of large PFOs was only 11%. The 23% prevalence of PFO in patients with TTH was not statistically different from 16% found in our normal control group. Furthermore, we found a significantly higher prevalence of PFO in migraineurs (50%) when compared with patients with tension headache (p < 0.001). This was also true for the collective presence of large PFOs and ASAs (35%) (p < 0.001). Although atrial septal anomalies have an association with MHA, they do not have a significant association with TTH.

A dumbbell thrombus entrapped in patent foramen ovale.

A 75-year-old lady came to emergency room due to dizziness and presyncopal attacks during exertion since two days prior to admission. Transesophageal echocardiography revealed a thrombus like mass in right atrium traversing patent foramen ovale and extending to left atrium. Spiral chest CT scan showed bilateral pulmonary thromboemboli. Operative and pathological findings confirmed the diagnosis.

The prevalence of coronary risk factors in Iranian lor migrating tribe.

Cardiovascular diseases are the major causes of death in Iran. The aim of this study was to determine the prevalence of conventional risk factors for coronary artery disease in Lor migrating tribes in southern part of Iran. Two hundred six persons of Lor migrating tribes in Mamasani, southern Iran (age range, 21 - 80 years) were randomly enrolled in the study. Their serum total cholesterol, triglyceride, high- density lipoprotein, low- density lipoprotein, and fasting blood sugar were determined. Of the participants, 79.9% were smokers. The prevalence of hypertension was 37.4% (mostly grade 1), 3.6% had diabetes mellitus, and 14.7% had impaired fasting glucose. A cholesterol level of more than 240 mg/dL was found in 7.1% of the participants, 27.8% had a low-density lipoprotein level of more than 130 mg/dL, 38.9% had a high-density lipoprotein level of less than 40 mg/dL, and 25.2% had a triglyceride level of more than 200 mg/dL. Body mass index greater than 25 was found in 34.8% of the participants, and 57.1% had intermediate and high risk for coronary events. The prevalence of conventional risk factors for coronary artery disease in Lor migrating tribes in comparison with Tehran urban population was very high.

The association of plasma high-sensitivity C-reactive protein level with rheumatic heart disease: The possible role of inflammation.

BACKGROUND: Currently, it is not clear whether recurrent traumatic events lead to progression of rheumatic heart disease (RHD) after the incident of acute rheumatic fever or a persistent inflammatory state at the site of the valves. The aim of this study was to assess the possible association between plasma high sensitive C Reactive Protein (hs-CRP) level as an indicator of inflammation and RHD. MATERIALS & METHODS: Ninety patients with RHD and 90 healthy controls who had undergone complete echocardiographic examination were enrolled in this cross-sectional study. A score was given to each patient according to the severity of valvular involvement. Plasma hs-CRP level was checked for each patient by ELISA method twice with two-week interval, and the mean hs-CRP was calculated. RESULTS: The mean plasma hs-CRP level in the case group was significantly higher compared to its level in the control group (2.59±4.82 and 0.55±0.43 in the case and control groups respectively, p<0.001). There was also a strong association between the level of plasma hs-CRP and the severity of rheumatic valvular involvement (p<0.001). CONCLUSION: The mean plasma hs-CRP level seems to have a significant association with RHD and its severity. Further studies are needed to determine the cause and effect relationship.

Aquarium sign in the left atrium.

A 50-year-old man presented with fever and chest pain. Later on the same day, he developed ischemic stroke and deteriorated into loss of consciousness. A trans-thoracic echocardiography showed air bubbles in the left atrium, resembling the floating bubbles in an aquarium. After further workups, atrio-esophageal fistula was diagnosed. To the best of our knowledge visualization of atrio-esophageal fistula by echocardiography has never been described previously.

The Nurse-Led Telephone Follow-Up on Medication and Dietary Adherence among Patients after Myocardial Infarction: A Randomized Controlled Clinical Trial.

BACKGROUND: Adherence to dietary and medication regimen plays an important role in successful treatment and reduces the negative complications and severity of the disease. Therefore, the present study aimed to investigate the effect of nurse-led telephone follow-up on the level of adherence to dietary and medication regimen among patients after Myocardial Infarction (MI). METHODS: This non-blinded randomized controlled clinical trial was conducted on 100 elderly patients with MI who had referred to the cardiovascular clinics in Shiraz. Participants were selected and randomly assigned to intervention and control groups using balanced block randomization method. The intervention group received a nurse-led telephone follow-up. The data were collected using a demographic questionnaire, Morisky's 8-item medication adherence questionnaire, and dietary adherence questionnaire before and three months after the intervention. Data analysis was done by the SPSS statistical software (version 21), using paired t-test for intra-group and Chi-square and t-test for between groups comparisons. Significance level was set at<0.05. RESULTS: The results of Chi-square test showed no statistically significant difference between the intervention and control groups with respect to their adherence to dietary and medication regimen before the intervention (P>0.05). However, a statistically significant difference was found between the two groups in this regard after the intervention (P<0.05). The mean differences of dietary and medication adherence scores between pre- and post-tests were significantly different between the two groups. Independent t-test showed these differences (P=0.001). CONCLUSION: The results of the present study confirmed the positive effects of nurse-led telephone follow-up as a method of tele-nursing on improvement of adherence to dietary and medication regimen in the patients with MI. TRIAL REGISTRATION NUMBER: IRCT201409148505N8.

Pulmonary artery stenosis caused by a large aortic arch pseudoaneurysm detected 10 years after a minor trauma.

Pseudoaneurysm of aorta is a rare condition usually seen after aortic surgeries or serious accidents. Here we report a 60 years old man without any previous medical condition who presented with non-specific symptoms and underwent different investigations for more than 1 year, until the presence of a continuous murmur raised suspicion toward his cardiovascular system. In echocardiographic and computed tomography (CT) angiographic studies a large pseudoaneurysm of aortic arch with compression effect on pulmonary artery was detected. At this stage he remembered having suffered a minor trauma 10 years ago. He finally underwent operation and his aortic wall was repaired successfully with a patch. This case highlights the importance of thorough history taking and physical examination in patients irrespective of symptoms and high index of suspicion to detect this life-threatening condition.

The Effect of Walnut Oil Consumption on Blood Sugar in Patients With Diabetes Mellitus Type 2.

BACKGROUND: Prevalence of diabetes mellitus type 2 (DM) is increasing globally. Considering the potential role of poly-unsaturated fatty acids in prevention of DM type 2 and lipid profiles improvement, some studies have been carried out on walnut. However, there are no studies on control of blood sugar in DM type 2 patients using walnut. OBJECTIVES: The current study aimed to evaluate the effect of walnut oil on blood sugar in DM type 2 patients. METHODS: This randomized control clinical trial was performed on 100 patients with DM type 2. For the experiment group (n = 50), walnut oil (15 g/day for three months) was added to their diet, while the control group (n = 50) did not undergo any interventions. Before initiation of the experiment and after the experiment, the systolic and diastolic blood pressure (SBP and DBP) levels, fasting blood sugar (FBS) and HbA1c were measured. RESULTS: The two groups were not significantly different for SBP, DBP, body weight, and Body Mass Index. HbA1c level decreased significantly in the experiment group by 7.86% ± 21.97 (P = 0.005) from 7.00 ± 1.08 before the intervention to 6.37 ± 1.29 after the intervention. Also, FBS level decreased significantly by 8.24% ± 16.77 (P = 0.001); from 158.37 ± 48.16 before the intervention to 137.91 ± 23.24 after the intervention in the experimental group. These changes in the control group were not significant. CONCLUSIONS: Consumption of walnut oil (15 g/day for three months) was shown to improve blood glucose level but, no changes were noted for bodyweight and blood pressure in type two diabetic patients.

Evaluation of the hemodynamic performance of St. Jude mitral prostheses: a pilot study by dobutamine-stress Doppler echocardiography.

In contrast to the widespread use of dobutamine stress Doppler echocardiography in the hemodynamic evaluation of the prosthetic valves in aortic position, it has been rarely, if ever, used for assessment of these valves in mitral position. Therefore, this pilot study was done to assess the hemodynamic performance of St. Jude prosthetic mitral valves (functional orifice area 25-31) with dobutamine-stress Doppler echocardiography. Twenty consecutive patients (13 women and 7 men, aged 23 to 42 years) who had undergone mitral valve replacement 6 to 4745 days previously and 16 healthy volunteers (5 women and 11 men, aged 18 to 42 years) underwent dobutamine-stress Doppler echocardiography. Dobutamine infusion was started at a rate of 5 microg/kg per minute and was increased by 5 microg increments at 3-minute intervals. Maximum and mean gradients as well as pressure halftime were measured at rest and at the end of each stage. The correlation between Doppler-derived variables versus the heart rate was assessed and a regression equation was obtained for each of them. A significant increase in blood pressure, heart rate, maximum and mean gradients was noted during dobutamine infusion in both groups. There was a significant positive linear correlation between the increasing transprosthetic mitral valvular maximum and mean gradients and the increments in the heart rate (G(max) = 4.47 + 0.093 [HR], r= 0.474, p<0.05) and (G(mean) = 3.0+0.003 [HR], r=0.2697, p<0.05), respectively, indicating the heart rate dependency of these parameters. Pressure halftime, on the other hand, had an inverse but linear relationship with the heart rate (PHT = 142 - 0.55 [HR], r= -0.577, p<0.05). Similar findings were found for the control group as well. Standard dobutamine-stress echocardiography can safely be performed in patients with St. Jude mitral valve prostheses. Single Doppler measurements of the pressure gradients and pressure halftime may yield erroneous conclusions regarding the function and size of these valves unless corrected for the patients simultaneous, online heart rate. The use of the regression equations obtained in this pilot study may help to partly overcome some of these difficult issues.

Absence of Correlation between Changes in the Number of Endothelial Progenitor Cell Subsets.

BACKGROUND AND OBJECTIVES: Previously, various methodologies were used to enumerate the endothelial progenitor cells (EPCs). We now know that these methodologies enumerate at least three different EPC subsets: circulating angiogenic cells (CACs), colony-forming unit endothelial cells (CFU-ECs), and endothelial colony-forming cells (ECFCs). It is not clear whether there is a correlation between changes in the number of these subsets. The aim of the current study is to find an answer to this question. MATERIALS AND METHODS: The number of all EPC subsets was quantified in the peripheral blood of nine pregnant women in their first and third trimesters of pregnancy. We enumerated 14 cell populations by quantitative flow-cytometry using various combinations of the markers, CD34, CD133, CD309, and CD45, to cover most of the reported phenotypes of CACs and ECFCs. Culturing technique was used to enumerate the CFU-ECs. Changes in the number of cells were calculated by subtracting the number of cells in the first trimester peripheral blood from the number of cells in the third trimester peripheral blood, and correlations between these changes were analyzed. RESULTS: The number of CFU-ECs did not correlate with the number of ECFCs and CACs. Also, CACs and ECFCs showed independent behaviors. However, the number of CACs showed a strong correlation with the number of CD133(+)CD309(+) cells (p=0.001) and a moderate correlation with the number of CD34(+)CD309(+) cells (p=0.042). Also, the number of ECFCs was correlated with the number of CD309(+)CD45(-) cells (p=0.029) and CD34(+)CD45(-) cells (p=0.03). CONCLUSION: Our study showed that the three commonly used methods for quantifying EPC subsets represent different cells with independent behaviors. Also, any study that measured the number of EPCs using the flow cytometry method with a marker combination that lacks CD309 may be inaccurate.

The Correlation between Echocardiographic Findings and QT Interval in Cirrhotic Patients.

BACKGROUND: Although many electrocardiographic abnormalities have been reported previously, prolonged QTC interval represented as the most important ECG finding in patients with liver cirrhosis. Echocardiography can detect structural cardiac abnormalities in cirrhotic patients. OBJECTIVES: The present study aimed to determine the correlation between QTC prolongation and echocardiographic findings in end stage liver cirrhosis. METHODS: The present study was conducted on 100 patients selected through convenient sampling. We recruited 80 cirrhotic patients with CHILD score > B or MELD score > 15 from the transplantation ward of Nemazee educational hospital. A complete echocardiographic study, including chamber quantification, a complete flow Doppler, and tissue Doppler analysis, was performed for each patient using a GE vivid 3 system equipped with Tissue Doppler Imaging (TDI). Then, twelve-lead ECG was carried out and QTc interval was calculated in all patients. The data were analyzed using the SPSS statistical software (v. 13) and Pearson's correlation coefficient. P value < 0.05 was considered statistically significant. RESULTS: The patients' age ranged from 20 to 60 years old and 62.5% of them were male. According to the results, the only parameter which was significantly associated with prolonged QTc interval was Left Ventricular End Diastolic Dimension (LVEDD). Additionally, a linear direct relationship was found between corrected QT interval and LVEDD (r = 0.41, P < 0.001). CONCLUSIONS: The current study showed a positive correlation between QTC prolongation as an electerocardiographic finding and LVEDD in echocardiography of the cirrhotic patients. This may indicate a direct relationship between the electrophysiological problems and the severity of volume overload in cirrhotic patients.

The effect of educational programs on hypertension management.

BACKGROUND: Hypertension is the main risk factor for cardiovascular diseases and stroke. Blood pressure control is a challenge for healthcare providers and the rate of blood pressure control is not more than 50% worldwide. OBJECTIVES: The present study aimed to determine the effectiveness of a short-term educational program on the level of knowledge, lifestyle changes, and blood pressure control among hypertensive patients. PATIENTS AND METHODS: This quasi-experimental study was conducted on the hypertensive patients attending Shiraz Healthy Heart House. In this study, 112 patients were selected via systematic random sampling. The study data were collected using a data gathering form which consisted of baseline characteristics and measurements of blood pressure. Multivariate analyses were used to assess the relationship between education and hypertension. RESULTS: At baseline, the scores of aware, treated, and controlled hypertensive patients were 21%, 20%, and 12%, respectively. However, these measures were increased to 92%, 95%, and 51%, respectively at the end of the study. The mean knowledge scores improved from 2.77 ± 2.7 to 7.99 ± 1.78 after 3 months (P < 0.001). Also, the mean lifestyle scores changed from 3.15 ± 1.52 to 4.53 ± 1.23 (P < 0.001). CONCLUSIONS: The results of the current study indicated that the educational programs were effective in increasing knowledge, improving self-management, and controlling detrimental lifestyle habits of the patients with hypertension.

Corrected QT interval and QT dispersion in cirrhotic patients before and after liver transplantation.

BACKGROUND: Liver cirrhosis is associated with different types of electrophysiological changes, including QT prolongation, which may adversely affect long-term prognosis of these patients. The aim of this study is to evaluate the effect of orthotopic liver transplantation (LT) on corrected QT (QTc) interval and QT dispersion (QTd) in cirrhotic patients of various etiologies. METHODS: We enrolled 249 patients with end-stage liver disease between 2004 and 2009 at Shiraz Transplant Research Center, Shiraz, Iran. The QTc interval and QTd were measured by 12 lead ECGs for baseline and at 3 months after LT. Mean QTc interval and mean QTd were calculated. A QTc interval above 440 ms was considered abnormal. RESULTS: Within 3 months following surgery, 6 patients died. There were 105 patients (43.2%) with prolonged QTc before transplantation; in 91 (86.6%) patients, the mean QTc normalized after transplantation (baseline: 490.9 ± 45.74 ms; post-transplantation: 385 ± 48.74 ms; P < 0.0001). Fourteen patients (13.3%) had evidence of some shortening of the QTc interval although the QTc remained above the upper limit of normal. Prolongation of the QTc interval in cirrhotic patients was independent of the etiology of cirrhosis. A normal QTc was seen in 138 patients (56.7%) before transplantation, of which 4 (2.9%) developed prolonged QTc after transplantation. The mean QTd decreased significantly after transplantation (baseline: 30 ± 20 ms; post-transplantation: 30 ± 10 ms; P < 0.0001). CONCLUSION: Many cirrhotic patients have prolonged QTc intervals before LT regardless of disease etiology. In the majority of patients this value returns to normal after LT, suggesting that liver cirrhosis has independent unfavorable, but reversible electrophysiological effects.