Cardio-oncology: Implications for Clinical Practice for Women.

PURPOSE OF REVIEW: Clinical cardio-oncology considerations specific to women span across many areas and are particularly relevant for management of patients with sex-specific cancers, such as breast cancer. RECENT FINDINGS: Major improvement in breast cancer survivorship over the last decade and the recognition of CV disease as the second leading cause of death among survivors point to the relevance of long-term cardiovascular (CV) safety. This review summarizes the CV effects associated with multimodality breast cancer treatments and contemporary approach to CV risk stratification, prevention, early detection, monitoring, and management at the time of cancer diagnosis, during and after completion of treatment. We highlight the growing role of a multidisciplinary, team-based approach for comprehensive CV and oncology care through the entire cancer treatment continuum, from diagnosis through survivorship.

Nanoscale Technologies for Prevention and Treatment of Heart Failure: Challenges and Opportunities.

The adult myocardium has a limited regenerative capacity following heart injury, and the lost cells are primarily replaced by fibrotic scar tissue. Suboptimal efficiency of current clinical therapies to resurrect the infarcted heart results in injured heart enlargement and remodeling to maintain its physiological functions. These remodeling processes ultimately leads to ischemic cardiomyopathy and heart failure (HF). Recent therapeutic approaches (e.g., regenerative and nanomedicine) have shown promise to prevent HF postmyocardial infarction in animal models. However, these preclinical, clinical, and technological advancements have yet to yield substantial enhancements in the survival rate and quality of life of patients with severe ischemic injuries. This could be attributed largely to the considerable gap in knowledge between clinicians and nanobioengineers. Development of highly effective cardiac regenerative therapies requires connecting and coordinating multiple fields, including cardiology, cellular and molecular biology, biochemistry and chemistry, and mechanical and materials sciences, among others. This review is particularly intended to bridge the knowledge gap between cardiologists and regenerative nanomedicine experts. Establishing this multidisciplinary knowledge base may help pave the way for developing novel, safer, and more effective approaches that will enable the medical community to reduce morbidity and mortality in HF patients.

Coronary microvascular dysfunction and cancer therapy-related cardiovascular toxicity.

BACKGROUND: Coronary microvascular dysfunction (CMD) has been implicated as a potential mechanism in the pathophysiology of different clinical presentations, including ischemia and no obstructive coronary artery disease (INOCA), myocardial infarction and nonobstructive coronary arteries (MINOCA), stress cardiomyopathy, heart failure, and myocarditis. There are limited data about the role of CMD in cancer therapy-related cardiovascular toxicities. CASE PRESENTATIONS: Four women with a diagnosis of active cancer receiving treatment who developed subsequent MINOCA or INOCA presented for cardiac catheterization. Upon coronary angiography showing no obstructive coronary arteries, coronary function testing was performed to evaluate for CMD. METHODS: Coronary physiology was assessed measuring non-hyperemic (resting full-cycle ratio [RFR]) and hyperemic (fractional flow reserve [FFR]) indices using a physiologic pressure wire. The wire also measured coronary flow reserve (CFR), index of microcirculatory resistance (IMR), and RFR using thermodilution technology. CMD was confirmed if the CFR was <2.5 and the IMR was >25. RESULTS: Among 4 patients with diagnosis of active cancer presenting with chest pain, there was no evidence of obstructive coronary artery disease, leading to separate diagnoses of INOCA, MINOCA, stress cardiomyopathy, and myocarditis. We found CMD in 2 patients (1 with INOCA and 1 with immune checkpoint inhibitor-related myocarditis). CONCLUSIONS: CMD may play a role in cardiovascular toxicities. Further coronary physiology studies are needed to understand the mechanisms of cancer therapy-related cardiovascular toxicity and CMD, as well as optimal preventive and treatment options.

Predictors and Risk Score for Immune Checkpoint-Inhibitor-Associated Myocarditis Severity.

Background: Immune-checkpoint inhibitors (ICI) are associated with life-threatening myocarditis but milder presentations are increasingly recognized. The same autoimmune process that causes ICI-myocarditis can manifest concurrent generalized myositis, myasthenia-like syndrome, and respiratory muscle failure. Prognostic factors for this "cardiomyotoxicity" are lacking. Methods: A multicenter registry collected data retrospectively from 17 countries between 2014-2023. A multivariable cox regression model (hazard-ratio(HR), [95%confidence-interval]) was used to determine risk factors for the primary composite outcome: severe arrhythmia, heart failure, respiratory muscle failure, and/or cardiomyotoxicity-related death. Covariates included demographics, comorbidities, cardio-muscular symptoms, diagnostics, and treatments. Time-dependent covariates were used and missing data were imputed. A point-based prognostic risk score was derived and externally validated. Results: In 748 patients (67% male, age 23-94), 30-days incidence of the primary composite outcome, cardiomyotoxic death, and overall death were 33%, 13%, and 17% respectively. By multivariable analysis, the primary composite outcome was associated with active thymoma (HR=3.60[1.93-6.72]), presence of cardio-muscular symptoms (HR=2.60 [1.58-4.28]), low QRS-voltage on presenting electrocardiogram (HR for ≤0.5mV versus >1mV=2.08[1.31-3.30]), left ventricular ejection fraction (LVEF) <50% (HR=1.78[1.22-2.60]), and incremental troponin elevation (HR=1.86 [1.44-2.39], 2.99[1.91-4.65], 4.80[2.54-9.08], for 20, 200 and 2000-fold above upper reference limit, respectively). A prognostic risk score developed using these parameters showed good performance; 30-days primary outcome incidence increased gradually from 3.9%(risk-score=0) to 81.3%(risk-score≥4). This risk-score was externally validated in two independent French and US cohorts. This risk score was used prospectively in the external French cohort to identify low risk patients who were managed with no immunosuppression resulting in no cardio-myotoxic events. Conclusions: ICI-myocarditis can manifest with high morbidity and mortality. Myocarditis severity is associated with magnitude of troponin, thymoma, low-QRS voltage, depressed LVEF, and cardio-muscular symptoms. A risk-score incorporating these features performed well. Trial registration number: NCT04294771 and NCT05454527.

Hypertension, smoking, and preexistence of multiple cardiac risk factors correlate with carfilzomib-induced cardiovascular adverse events in a racially diverse population.

Background: Use of the proteasome inhibitor carfilzomib has become a standard of care in patients with relapsed/refractory multiple myeloma. An association between carfilzomib and cardiovascular adverse events has been well documented, but this had not been investigated in a racially diverse population. Black patients in particular are underrepresented in the reported outcomes of treatment with carfilzomib. Objective: The purpose of this study was to identify risk factors for carfilzomib-associated cardiovascular events in a diverse, single-center population. Methods: We conducted a retrospective review of 161 patients with multiple myeloma treated with carfilzomib between 2011 and 2020 at the University of Maryland Medical Center. Over half (86) were Black patients, with the remainder (75) being White patients. We did a multivariate analysis to determine risk factors for developing cardiovascular events during treatment with carfilzomib. Results: There was no statistically significant association with cardiotoxicity and race, gender, or age at first dose of carfilzomib. In multivariable analysis, patients with history of hypertension had a higher risk of cardiotoxicity [adjusted odds ratio (OR): 2.5; 95% CI: 1.1-5.9; P = 0.03] as did those with a history of smoking [OR: 2.8; 95% CI: 1.3-6.4; P = 0.01]. Conclusions: Here we report the largest cohort of Black patients treated with carfilzomib as yet reported. The results of this single center retrospective study show history of hypertension and smoking are associated with carfilzomib associated cardiotoxicity in a diverse patient population. There is a need for well-designed prospective studies enrolling a diverse population to investigate potential interventions to prevent carfilzomib-associated cardiotoxicity.

Glycosylated hemoglobin (HbA1c) levels and clinical outcomes in diabetic patients following coronary artery stenting.

BACKGROUND: Diabetes has been shown to be independent predictor of restenosis after percutaneous coronary intervention (PCI). The aim of the present study was to investigate whether a pre- and post-procedural glycaemic control in diabetic patients was related to major advance cardiovascular events (MACE) during follow up. METHODS: We evaluated 2884 consecutive patients including 2181 non-diabetic patients and 703 diabetics who underwent coronary stenting. Diabetes mellitus was defined as the fasting blood sugar concentration ≥ 126 mg/dL, or the use of an oral hypoglycemic agent or insulin at the time of admission. Diabetic patients were categorized into two groups based on their mean HbA1c levels for three measurements (at 0, 1, and 6 months following procedure): 291 (41.4%) diabetics with good glycaemic control (HbA1c ≤ 7%) and 412 (58.6%) diabetics with poor glycaemic control (HbA1c > 7%). RESULTS: The adjusted risk of MACE in diabetic patients with poor glycaemic control (HbA1c > 7%) was 2.1 times of the risk in non-diabetics (adjusted HR = 2.1, 95% CI: 1.10 to 3.95, p = 0.02). However, the risk of MACE in diabetics with good glycaemic control (HbA1c ≤ 7%) was not significantly different from that of non-diabetics (adjusted HR = 1.33, 95% CI: 0.38 to 4.68, p = 0.66). CONCLUSIONS: Our data suggest that there is an association between good glycaemic control to obtain HbA1c levels ≤7% (both pre-procedural glycaemic control and post-procedural) with a better clinical outcome after PCI.

Sodium bicarbonate in preventing contrast nephropathy in patients at risk for volume overload: a randomized controlled trial.

BACKGROUND: Sodium bicarbonate has been recently proposed as a prophylactic measure for the prevention of contrast-induced nephropathy (CIN). We aimed to compare the efficacy of the combination of sodium bicarbonate with half saline, and half saline alone in preventing CIN in patients having uncontrolled hypertension, compensated severe heart failure or a history of pulmonary edema. METHODS: Seventy-two patients undergoing elective coronary angiography with a serum creatinine level > or =1.5 mg/dL who had uncontrolled hypertension, compensated severe heart failure or a history of pulmonary edema were prospectively enrolled in a single-center, double-blind, randomized, controlled trial from August 2007 to July 2008 and were assigned to either an infusion of sodium bicarbonate plus half saline (n=36) or half saline alone (n=36). The primary end point was an absolute (> or =0.5 mg/dL) or relative (> or =25%) increase in serum creatinine 48 hours after the procedure (CIN). RESULTS: There were no significant differences between the groups regarding their baseline demographic and biochemical characteristics, as well as the underlying disease. A total of 6.1% of the patients receiving sodium bicarbonate plus half saline developed CIN as opposed to 6.3% of the patients in the half saline group, which was not statistically different (odds ratio = 0.97; 95% confidence interval, 0.13-7.3; p=1.0). CONCLUSION: The combination therapy of sodium bicarbonate plus half saline does not offer additional benefits over hydration with half saline alone in the prevention of CIN.

Endovascular Repair of a Common Carotid Pseudoaneurysm in a Patient with Behçet's Disease: A Case Report and Review of Literature.

Behçet's disease (BD) is a multisystem inflammatory disorder. Physicians should be alerted to the possibility of BD in a patient with a carotid artery pseudoaneurysm and no clear predisposing factor such as neck trauma or surgery. Endovascular repair of carotid pseudoaneurysms is technically feasible with excellent midterm follow-up results. Administration of immunosuppressive therapy before endovascular intervention is mandatory to reduce the chance of vascular complications accompanied by BD. A 40-year-old man presented with a painful and pulsatile neck mass with 2 episodes of transient ischemic attacks. The patient also complained of recurrent urogenital ulcers and aphthous lesions together with painful rashes. Ultrasonography and computed tomography angiography revealed 2 aneurysmal dilations in the left common carotid artery at the bifurcation level. He was referred to a rheumatologist, who made the diagnosis of BD. High-dose corticosteroids and cyclophosphamide were commenced. One week later, 2 overlapping self-expanding stent grafts were deployed. The final angiogram showed no residual endoleak, and the flow of the carotid and cerebral arteries was satisfactory. The patient was discharged with no neurological complications. Follow-up ultrasonography and computed tomography angiography 6 months later showed no endoleak, as well as significant shrinkage of the aneurysm sac.

Twelve-Year History of STEMI Management in Tehran Heart Center: Concomitant Reduction of In-Hospital Mortality and Hospitalization Length.

BACKGROUND: Cardiovascular-related death remains the major cause of mortality in Iran despite significant improvements in its care. In the present study, we report the in-hospital mortality, hospitalization length, and treatment methods for patients with ST-elevation myocardial infarction (STEMI) in Tehran Heart Center (THC). METHODS: Records pertaining to patients with STEMI from March 2006 to March 2017 were extracted from the databases of THC. Besides a description of temporal trends, multivariable regression analysis was used to find factors associated with in-hospital mortality. RESULTS: During the study period, 8,295 patients were admitted with STEMI with a mean age of 60.4 ± 12.5 years. Men accounted for 77.5% of the study population. Hospitalization length declined from 8.4 to 5.2 days, and in-hospital mortality was reduced from 8.0% to 3.9% (both P values < 0.001). In a multivariable model adjusted for age, sex, conventional cardiac risk factors, prior cardiac history, and indices of event severity, primary percutaneous coronary intervention (PCI) (OR: 0.280, 95% CI: 0.186 to 0.512; P<0.001), coronary artery bypass graft (CABG) surgery (OR: 0.482, 95% CI: 0.220 to 0.903; P=0.025), and rescue or facilitated PCI (OR: 0.420, 95% CI: 0.071 to 0.812; P=0.001) were all associated with reduced in-hospital mortality in comparison with medical treatment. Furthermore, primary PCI was a crucial protective factor against prolonged length of hospital stay (OR: 0.307, 95% CI: 0.266 to 0.594; P<0.001). CONCLUSION: In-hospital mortality and hospitalization length were almost halved during the study period, and primary PCI has now replaced thrombolysis in the management of STEMI.

Sodium bicarbonate plus isotonic saline versus saline for prevention of contrast-induced nephropathy in patients undergoing coronary angiography: a randomized controlled trial.

BACKGROUND: There is controversy about the prophylactic measures proposed for the prevention of contrast-induced nephropathy (CIN). We aim to compare the efficacy of the combination of sodium bicarbonate and isotonic saline and that of isotonic saline alone in preventing CIN. STUDY DESIGN: Randomized double-blind controlled trial. SETTING & PARTICIPANTS: 265 consecutive patients 18 years or older with a serum creatinine level of 1.5 mg/dL or greater undergoing elective coronary angiography from August 2007 to June 2008 in Tehran Heart Center, Tehran, Iran. INTERVENTION: Study participants were randomly assigned to receive either 75 mL of 8.4% sodium bicarbonate added to 1 L of isotonic saline (n = 135) or isotonic saline alone (n = 130) as a bolus of 3 mL/kg for 1 hour before contrast injection, followed by an infusion of 1 mL/kg/h for 6 hours after the procedure. OUTCOMES & MEASUREMENTS: The primary end point was an absolute (>or=0.5 mg/dL) or relative (>or=25%) increase in serum creatinine level 48 hours after the procedure (CIN). RESULTS: There were no significant differences between the bicarbonate and saline groups regarding baseline demographic and biochemical characteristics, including baseline serum creatinine level (1.63 +/- 0.32 [SD] versus 1.66 +/- 0.50 mg/dL), baseline glomerular filtration rate (46.4 +/- 12 versus 45.4 +/- 12 mL/min/1.73 m(2)), and baseline urine pH (5.42 +/- 0.6 versus 5.46 +/- 0.8). Nine patients (7.4%) receiving sodium bicarbonate developed CIN as opposed to 7 patients (5.9%) in the saline group, which was not statistically different (odds ratio, 1.26; 95% confidence interval, 0.45 to 3.50; P = 0.6). LIMITATIONS: The trial did not follow up participants to assess need for dialysis and mortality rate. CONCLUSION: The combination therapy of sodium bicarbonate plus saline does not offer additional benefits over hydration with saline alone in the prevention of CIN.

Factors predicting discontinuation of a hospital-based cardiac rehabilitation programme.

BACKGROUND: Cardiac rehabilitation (CR) programmes play an important role in the management of patients with coronary artery disease. However, a significant proportion of patients do not participate or do not complete CR. AIM: To asses the prevalence and predictors of discontinuation of a hospital-based CR programme and to investigate whether or not the completers and dropouts differed in relation to their baseline characteristics. METHODS: Data used for analysis were from a hospital-based CR programme involving 1986 discharged patients at Tehran Heart Centre between July 2004 and January 2006. The patients who completed all 24 sessions of the CR programme were compared with the dropouts. RESULTS: The CR completion rate was 18.1% (average of 11.4+/-8.1, ranging from 1 to 78 sessions) including patients who completed 24 (n=284) or more sessions (n=77) of the CR programme. Factors predicting dropout were male gender (OR 1.441, p=0.0094), younger age (OR 0.979, p=0.005), and lower levels of education (OR 0.412, p <0.0001). CONCLUSION: The present study demonstrated a relatively high rate of CR programme dropout. Only less than a fifth of the patients completed this hospital-based programme. Patients who were male and younger and had lower education levels were better likely to drop out of the CR programme. Social support and educational programmes may be helpful in achieving better compliance.

The Association Between Modified Intracoronary Thrombus Grade and Cardiovascular Risk Factors and Initial Laboratory Findings in Patients Undergoing Primary Percutaneous Coronary Intervention.

The thrombus burden has been shown to affect the immediate results of primary coronary intervention and the outcome of the patients. The aim of the present study was to determine the cardiovascular risk factors and initial laboratory findings associated with angiographic thrombotic grade based on the new reclassified grading method. A total of 394 consecutive patients presenting with a first ST-elevation myocardial infarction treated by primary coronary intervention were retrospectively evaluated between March 2014 and March 2017. Patients were divided into 2 groups of low thrombus grade (grades 1-3) and high thrombus grade (grade 4). The results showed that the patients with high thrombus grade had markedly higher white blood cell (WBC) counts, platelet counts, and initial troponin levels (P values were <0.001, 0.004, and <0.001, respectively). After logistic regression analysis, high WBC count had the strongest association with high thrombus grade [odds ratio: 3.185, 95% confidence interval: 1.349-7.520; P = 0.008]. The initial troponin level also had significant association with high thrombus grade, whereas high platelet count had a borderline statistical significance (odds ratio: 2.250, 95% confidence interval: 0.928-5.459; P = 0.073). In conclusion, the present study demonstrated that high WBC and higher levels of baseline troponin were associated with high angiographic thrombus grade in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Effect of Various Degrees of Chronic Kidney Disease on Long-term Outcome of Patients with Percutaneous Coronary Intervention.

BACKGROUND: We aimed to identify the association of degree of renal failure in chronic kidney disease patients who underwent percutaneous coronary intervention (PCI) at our center with 5-year major adverse cardiac events (MACE). METHODS: In this cohort study, we enrolled all patients who underwent primary or elective PCI and completed their 5-year followup unless they developed events related to study end-points. Demographic, angiographic and clinical data of the participants were retrieved from our databank. Glomerular filtration rate (GFR) was calculated based on the Cockcroft-Gault equation for men and women, separately. Accordingly, our patients were classified into three groups: GFR ≥ 60, GFR < 60 and ≥30 and GFR < 30 mL/ min. Then, the demographic and clinical data, as well as the frequency of MACE and its elements, were compared between the study groups. RESULTS: We included the data for 5,510 patients. MACE occurred in 891 (16.1%) of the patients. A total of 632 cases (16.7%) occurred in patients with GFR > 60 while 224 cases (18.8%) and 35 events (43.7%) occurred in patients with 30 ≤ GFR < 60 and GFR < 30 mL/min, respectively. So, GFR < 30 mL/min was significant predictor for MACE (hazard ratio [HR] = 3.74, 95% CI: 2.64-5.28; P < 0.001). The prediction effect of GFR < 30 remained significant after adjustment for the confounding variables (HR = 3.43, 95% CI: 2.38-4.94; P < 0.001). CONCLUSION: GFR <30 mL/min was a strong predictor for 5-year MACE. Moreover, in patients with GFR > 30 mL/min, PCI is a more applicable approach.

Effect of Age on Procedural Success, Complications, and Clinical Outcome From a Large Angioplasty Registry.

BACKGROUND: Increasing age appears to be a risk factor for adverse outcome in patients undergoing percutaneous coronary intervention (PCI). The goal of this study was to compare procedural success, complications, and 12 months major adverse cardiac events (MACE) based on age using a large angioplasty registry. METHODS: This registry included 10,412 patients with at least 12-month follow-up from April 1993 to April 2011. Patients were divided into 3 age groups: group 1 age < 60 (n = 6195), group 2 age 60-75 (n = 3724) and group 3 elderly age ≥ 75 (n = 493). RESULTS: Procedural success rate was not significantly different across the 3 age groups. (96.9% in group 1, 97.1% in group 2, and 96.1% in elderly group, P = 0.759). Procedural complications occurred in 179 (2.9%) of group 1, 98 (2.6%) of group 2 and 15 (3.0%) of elderly group (P = 0.678). In-hospital complications increased with increasing age (311 [5.0%] in group 1, 235 [6.3%] in group 2, and 46 [9.3%] in elderly group; P < 0.001). Twelve-month MACE also increased with increasing age (235 [4.1%] in group 1, 169 [4.9%] in group 2 and 26 [5.7%] in elderly group; P = 0.021). Multivariate analysis showed that age was not a predictor for unsuccessful PCI, procedural complications, or 12-month MACE. However, increasing age was independent predictors of in-hospital complications and death. CONCLUSION: Despite increased in-hospital complications with increasing age, procedural success, and complications were not higher in elderly. Our data suggest that PCI should not be denied in elderly if indicated with procedural safety similar to other age groups.

Transcatheter closure of a coronary fistula with an Amplatzer vascular plug: should a retrograde approach be standard?

Coronary artery fistulae are rare disorders. Only 2 reports in the medical literature discuss the use of vascular plugs to occlude coronary fistulae, and the same device-the Amplatzer Vascular Plug-was deployed via different techniques to treat those patients. The safety, the feasibility, and the standard approach to deployment have yet to be established. Herein, we describe the case of a 15-year-old boy who presented with a continuous murmur at the left sternal border. The patient was diagnosed with a large coronary fistula that originated from the right coronary artery and emptied into the right atrium. He underwent transcatheter closure of the fistula. We placed a 14-mm Amplatzer Vascular Plug into the narrowest part of the fistula, which resulted in complete occlusion and an excellent outcome. Our retrograde approach is simple and obviates the need to establish arteriovenous loops or to insert additional devices, such as coils. In this report, we compare our results with those of the 2 previous reports. To our knowledge, this is only the 2nd report that describes the closure of a coronary fistula in an adolescent patient by use of an Amplatzer Vascular Plug.

In-hospital and late clinical outcomes of direct stenting strategy versus stenting after predilatation for the treatment of coronary artery lesions.

BACKGROUND: Direct stenting without balloon dilatation may reduce procedural costs and duration, and hypothetically, the restenosis rate. This study was designed to compare the in-hospital and long-term outcomes of direct stenting (DS) versus stenting after predilatation (PS) in our routine clinical practice. METHODS: One thousand six hundred and three patients treated with stenting for single coronary lesions were enrolled into a prospective registry. Patients with acute myocardial infarction (MI) within the preceding 48 hours, highly calcified lesions, total occlusions, or lesion in a saphenous graft were excluded. The baseline, angiographic, and procedural data, in-hospital outcomes and follow-up data were recorded in our database, and analyzed with appropriate statistical methods. RESULTS: Eight hundred and fifty-seven patients (53.5%) were treated with DS, whereas 746 of them (46.5%) underwent PS. In the DS group, lesions were shorter in length, larger in diameter, and had lower pre-procedural diameter stenosis. Type C and diffuse lesions and drug-eluting stents were less frequent (p < 0.001). In univariate analysis, dissection and non-Q-wave MI occurred less frequently in this group (0.2% and 0.6% vs 3.9% and 2.1%, p < 0.001 and p 7 = 0.01, respectively). However, the cumulative major adverse cardiac events (MACE) did not differ significantly (4.9% vs 4.6%, p = 0.79). In multivariate analysis, direct stenting reduced the risk of dissection (OR = 0.07, 95% CI: 0.01-0.33), but, neither the cumulative endpoint of MACE (OR = 1.1, 95% CI = 0.58-2.11, p = 0.7) nor its constructing components were different between the groups. CONCLUSIONS: Direct stenting in real world has at least similar long-term outcomes with patients treated with stenting after predilatation and is associated with lower dissection rate.

The association between coronary arterial dominancy and extent of coronary artery disease in angiography and paraclinical studies.

The association between coronary arterial dominance patterns and the coronary artery diameter, length, and valvular heart diseases were previously studied. However, its association with coronary artery disease (CAD) is unclear. We investigated to determine whether the extent and localization of CAD differ in right, left, or codominant coronary arterial patterns. Twelve thousand five hundred fifty-eight patients admitted to Tehran Heart Center for coronary angiography were studied retrospectively (2004-2006). The extent and localization of CAD and the dominant artery were determined. There were 62.7% males. The mean age was 57.6 +/- 10.3. 84.2% [95% confidence interval (CI); 83.6-84.8%], 10.9% (95% CI; 10.4-11.4%), and 4.8% (95% CI; 4.4-5.2%) of the patients were right, left, and codominant, respectively; No significant difference considering age, sex, positive family history, hypertension, hyperlipidemia, electrocardiography, exercise treadmill stress test, and perfusion scan were seen in the groups. The right-dominant patients tend to have three-vessel disease (33.1% vs. 27%, P < 0.0001), stenosis of more than 50% in right coronary artery (65.9% vs. 57.9%, P < 0.0001) and left circumflex territories (64% vs. 59.4%, P = 0.01), more than the left-dominant patients. The involvements of the left main coronary artery, left anterior descending artery territory, and posterior descending artery were not significantly different. This study demonstrates a relationship between angiographic CAD severity, and the involved arterial territory and dominancy patterns.

Catheter-Directed Thrombolysis in Acute Iliofemoral Deep Vein Thrombosis with or without Stenting: A Case Series.

Iliofemoral deep vein thrombosis (IFDVT) is a potentially devastating condition comprising a quarter of all cases of lower extremity DVT. It can lead to serious consequences such as pulmonary embolism, limb malperfusion, and post-thrombotic syndrome (PTS), which is a chronic sequela of IFDVT. We herewith present 18 IFDVT cases managed with catheter-directed thrombolysis at our hospital. Nine of these patients underwent stenting of the involved iliac veins. The remaining 9, who did not receive stenting, had a residual stenosis of more than 50% in the common femoral or iliac veins following the procedure. Based on a final residual stenosis of less than 50% in the iliac veins, we had 9 successful (patients with stenting) and 9 unsuccessful procedures (patients without stenting). In subsequent follow-ups at a median follow-up of 39.5 months, using the Villalta score, while only 2 out of the 9 patients who underwent stenting suffered PTS, 4 patients among the other 9 patients comprising the non-stenting group developed PTS. Our results support the notion that stenting might have a role in decreasing the PTS risk in patients undergoing catheter-directed thrombolysis.

Novel Scoring System for Prediction of Cardiac Syndrome X in Women with Typical Angina and a Positive Exercise Tolerance Test.

A major diagnostic challenge for cardiologists is to distinguish cardiac syndrome X (CSX) from obstructive coronary artery disease in women with typical angina and a positive exercise tolerance test (ETT). We performed this study to develop a scoring system that more accurately predicts CSX in this patient population. Data on 976 women with typical angina and a positive ETT who underwent coronary angiography at our center were randomly divided into derivation and validation datasets. We developed a backward stepwise logistic regression model that predicted the presence of CSX, and a scoring system was derived from it. The derivation dataset (809 patients) was calibrated by uing a Hosmer-Lemeshow goodness-of-fit test (8 degrees of freedom; χ2=12.9; P=0.115), and the area under the curve was 0.758. The validation dataset (167 patients) was calibrated in the same way (8 degrees of freedom; χ2=9.0; P=0.339), and the area under the curve was 0.782. Independent predictors of CSX were age <55 years; negative histories of smoking, diabetes mellitus, hyperlipidemia, hypertension, or familial premature coronary artery disease; and highly positive ETTs. A total score >9.5 was the optimal cutoff point for differentiating CSX from obstructive coronary artery disease. Our proposed scoring system is a simple, objective, and accurate system for distinguishing CSX from obstructive coronary artery disease in women with typical angina and positive ETTs. It may help determine which of these patients need invasive coronary angiograms or noninvasive tests like computed tomographic coronary angiography.

Comparing Serum Level of Vitamin D3 in Patients With Isolated Coronary Artery Ectasia and Normal Coronary Artery Individuals.

BACKGROUND: Coronary artery ectasia (CAE) is identified as dilation of one or more segments of coronary arteries that reaches 1.5 times or more, compared with near segments that are normal. Several etiologies like atherosclerosis, autoimmune diseases and congenital anomalies have been proposed for this condition. Vitamin D deficiency activates the renin-angiotensin-aldosterone system, which affects the cardiovascular system. For these reasons, we investigated the serum level of vitamin D in patients with CAE compared with individuals with normal coronary arteries. METHODS: The study group included 30 patients (20 males and 10 females, mean age: 57 ± 9 years) with isolated CAE without any stenotic lesions, and the control group consisted of 60 age/gender matched subjects who had normal coronary angiograms (CAG) (40 males and 20 females, mean age: 57 ± 8 years). All participants underwent CAG at Tehran Heart Center between December 2015 and March 2016. Along with routine lab tests, vitamin D, serum albumin, calcium, phosphorus and alkaline phosphatase levels were analyzed and the unadjusted and adjusted effects of vitamin D on CAE were evaluated using logistic regression model. RESULTS: The median vitamin D level of the patients with CAE was lower than that of the control group (6.5 [3.0, 18.8] ng/mL vs. 17.7 [8.9, 27.1] ng/mL; P = 0.002). The logistic regression model showed that vitamin D deficiency was a predictor for the presence of CEA (P = 0.013). After adjustment for confounding variables, this association remained significant (P = 0.025). CONCLUSION: An association between CAE and vitamin D deficiency was found in our study.