Changes in Heart Rate Variability Parameters Following Radiofrequency Ablation in Patients with Atrial Fibrillation: A Systematic Review and Meta-Analysis.

PURPOSE: Radiofrequency (RF) ablation is a prevalent treatment for atrial fibrillation (AF), targeting triggers within the pulmonary vein (PV) for elimination. This study evaluated heart rate variability (HRV) parameter changes at three intervals post-RF ablation: short-term (immediately to 1 month), medium-term (1 to 6 months), and long-term (6 months to 1 year). We compared two ablation techniques: circumferential PV isolation (CPVI) and segmental PV isolation (SPVI). METHODS: A thorough search of databases, including PubMed, Embase, Scopus, Web of Science, and Cochrane, in 2022 yielded 835 pertinent studies. After inclusion criteria were applied, 22 studies were analyzed. RESULTS: Results showed a marked decline in HRV parameters post-AF ablation, with LF/HF as an exception. These reductions persisted in short- and long-term evaluations up to a year post-procedure. Subgroup analysis revealed significant HRV declines, with distinct LF/HF values post-SPVI. CONCLUSION: This meta-analysis suggests the potential of decreased HRV as an indicator of autonomic denervation, necessitating further exploration to optimize therapeutic strategies and enhance patient outcomes.

A qualitative report on experiences of participants in the young innovative leadership program.

BACKGROUND: Leadership in health system is a universal challenge. The Young Innovative Leadership Program (YILP) designed for undergraduate and postgraduate medical sciences students, implemented at the Isfahan University of Medical Sciences, aimed to cultivate leadership capacities through a 16-week training program. This program comprises ten modules covering innovation, change leadership, and management skills, with mentor-facilitated group discussions. This study aimed to provide a qualitative report of the experiences of participants in the YILP. METHODS: A qualitative study was conducted in 2022, three months after the end of the training program, to investigate the participants' perspectives. Data was extracted through in-depth, semi-structured interviews with 14 participants. RESULTS: In this study 14 undergraduate and postgraduate medical sciences students who had participated in the YILP the previous year were included. Four main categories emerged from the interviews: "emergence of new horizons", "values as beacon", "an expanded toolbox", and "program's structure: a learning atmosphere". CONCLUSIONS: The results of our study indicated that medical science students would benefit from leadership development programs. In this regard, the framework utilized to implement YILP could serve as a role model.

First Iranian guidelines for the diagnosis, management, and treatment of hyperlipidemia in adults.

This guideline is the first Iranian guideline developed for the diagnosis, management, and treatment of hyperlipidemia in adults. The members of the guideline developing group (GDG) selected 9 relevant clinical questions and provided recommendations or suggestions to answer them based on the latest scientific evidence. Recommendations include the low-density lipoprotein cholesterol (LDL-C) threshold for starting drug treatment in adults lacking comorbidities was determined to be over 190 mg/dL and the triglyceride (TG) threshold had to be >500 mg/dl. In addition to perform fasting lipid profile tests at the beginning and continuation of treatment, while it was suggested to perform cardiovascular diseases (CVDs) risk assessment using valid Iranian models. Some recommendations were also provided on lifestyle modification as the first therapeutic intervention. Statins were recommended as the first line of drug treatment to reduce LDL-C, and if its level was high despite the maximum allowed or maximum tolerated drug treatment, combined treatment with ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitors, or bile acid sequestrants was suggested. In adults with hypertriglyceridemia, pharmacotherapy with statin or fibrate was recommended. The target of drug therapy in adults with increased LDL-C without comorbidities and risk factors was considered an LDL-C level of <130 mg/dl, and in adults with increased TG without comorbidities and risk factors, TG levels of <200 mg/dl. In this guideline, specific recommendations and suggestions were provided for the subgroups of the general population, such as those with CVD, stroke, diabetes, chronic kidney disease, elderly, and women.

QTc interval measurement in patients with right bundle branch block: A practical method.

BACKGROUND AND AIM: Prolonging the QT interval in the right bundle branch block (RBBB) can create challenges for electrophysiologists in estimating repolarization time and eliminating the effect of depolarization changes on QT interval. In this study, we aimed to develop a practice formula to eliminate the effect of depolarization changes on QT interval in patients with RBBB. METHODS: This prospective study evaluated accidentally induced RBBB in patients undergoing electrophysiological study. Two expert electrophysiologists recorded the ECG parameters, including QRS duration, QT interval, and cycle length, in the patients. The formula was developed based on QT interval differences (with and without RBBB) and its proportion to QRS. Additionally, the Bazzet, Rautaharju, and Hodge formulas were used to evaluate QTc. RESULTS: We evaluated 96 patients in this study. The mean QT interval without RBBB was 369.39 ± 37.38, reaching 404.22 ± 39.23 after inducing RBBB. ΔQT was calculated as 34.83 ± 17.61, and the ratio of ΔQT/QRS with RBBB was almost 23%. Our formula is: (QTwith RBBB  - 23% × QRS). Subtraction of 25% instead of 23% seems more straightforward and practical. Our formula could also predict the QTc interval in RBBB based on the Bazzet, Rautaharju, and Hodge formulas. CONCLUSION: Previous formulas for QT correction were hard to apply in the clinical setting or were not specified for RBBB. Our new formula allows a rapid and practical method for QT correction in RBBB in clinical practice.

Electrophysiological and therapeutic effects of amiodarone in patients with preexcited atrial fibrillation.

Background: Atrial fibrillation (AF) with fast ventricular response over an overt accessory pathway (AP) (preexcited AF) with a short anterograde refractory period is a potentially malignant arrhythmia. This study aimed to evaluate the safety and efficacy of amiodarone for preexcited AF management. Materials and Methods: This study enrolled 103 patients with evidence of AP in electrocardiography. Patients with preexcited AF were included in the study. Intravenous amiodarone (300 mg) was infused for 30 min for all patients in the AF rhythm. Electrophysiological parameters were evaluated before amiodarone injection and 2 h after pharmacological or electrical cardioversion. Results: Antegrade and retrograde refractory periods of the atrioventricular node (AVN) and AP, as well as antegrade and retrograde Wenckebach points of AVN, were increased significantly after amiodarone infusion. Furthermore, the mean of the shortest preexcited RR interval was increased during the monitoring period. Comparing the preexcited index at the beginning of the study and before cardioversion (2 h later) revealed that the QRS complexes changed to a wider pattern as the preexcitation index changed from 80.61 to 92.26 (P < 0.001). Nineteen (18.4%) patients converted to the sinus rhythm with amiodarone infusion. No ventricular arrhythmia was detected during monitoring. Conclusion: Amiodarone could be considered a safe drug in patients with preexcited AF for rate control despite its relatively low efficacy in conversion to the sinus rhythm.

Effect of fenugreek consumption on serum lipid profile: A systematic review and meta-analysis.

Various studies have shown that Trigonella foenum-graecum (fenugreek) supplementation has lipid-lowering activity. This meta-analysis was performed to evaluate the effect of fenugreek supplementation on human serum lipid profile. Data sources were PubMed, EMBASE, Scopus, and Coherence library which were searched systematically from January 2000 up to December 2019. Inclusion criteria were randomized clinical trial (RCT) study design, at least one of lipid profile components (triglyceride [TG], total cholesterol [TC], low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol) levels measured before fenugreek use and one of the lipid components level reported as result. The pooled weighted mean difference (MD) and its 95% confidence interval (CI) were calculated and pooled using a random-effect model. Only articles published in English were considered. Fifteen RCTs involving 281 cases consumed fenugreek and 255 control cases in controlled group (11 articles) and 136 cases in uncontrolled group (4 articles) were analyzed in our study. Pooled data of indicated a significant impact of fenugreek supplementation on lowering TC (-1.13 [-1.88, -0.37]; p = .003), low-density lipoprotein (LDL) (-1.26 [-2.09, -0.43]; p = .003), and TG (-1.07 [-1.82, -0.33]; p = 0.005) and increasing the high-density lipoprotein (HDL) level (0.70 [0.07, 1.34]; p = .03) compared with the control group. There were no significant differences in TC, TG, and LDL between pre- and post-fenugreek studies in the noncontrolled studies however, the result of combination of four studies without control group showed a significant increase in mean HDL (0.81 [0.33,1.29]; p-value = .001). The results of subgroup analysis showed that the fenugreek reduced the TG and LDL and increases HDL levels in diabetic subjects more effectively. Fenugreek supplementation significantly improved lipid profile (LDL, TG, TC, and HDL). It could be considered as an effective lipid-lowering medicinal plant. Further high-quality studies are needed to firmly establish the clinical efficacy of the plant.

Presentation, Management and Early Mortality of Patients with Acute Coronary Syndrome in a Large Sample Study of a Middle East Country.

Background: Due to lack of contemporary data on the presentation, management, and mortality of acute coronary syndrome (ACS) admissions in Iran, in this prospective registry study, we aimed to evaluate the presentation, management, and mortality as the outcome of patients with ACS in Isfahan, Iran, 2001-2016 to address treatment and healthcare depletions. Methods: Data of 62,276 patients admitted with the diagnosis of ACS from 2001 to 2016 prospectively were obtained by Surveillance Unit of Isfahan Cardiovascular Research Center, Isfahan, Iran, in 13 hospitals of Isfahan province. We evaluated data on presentation, management, and in-hospital and 28-day mortality. Results: Nearly half of the patients ranged in age from 51 to 70 years (32050, 51.5%), which did not differ among ACS types (ST-segment myocardial infarction (STEMI): 53.9%; non-STEMI: 53.4%; unstable angina: 51.9%). In-hospital, anti-platelets use was high (84.9%). Thrombolytic were used in 48.1% of STEMI, 3.8% of non-STEMI, and 1.1% of unstable angina. Discharge medication rates were suboptimal. In-hospital and 28-day mortality were highest for STEMI (6.5 and 12.6%, respectively). Conclusions: These data represent the large ACS registry in Iran. Data revealed the various presentations of ACS and demonstrated opportunities for improving ACS management by focusing on increasing use of recommended drugs especially after discharge due to suboptimal medical treatment in these patients. The high mortality rate needs to be taken into consideration in ACS patients.

Comparative Evaluation of Captopril, Spironolactone, and Carvedilol Effect on Endothelial Function in Breast Cancer Women Undergoing Chemotherapy.

Background: Breast cancer is the most prevalent malignancy in females which needs chemotherapy treatment. Studies demonstrated that anti-cancer agents used for chemotherapy in cancer patient causes endothelium dysfunction. Several researches showed the efficacy of angiotensin-converting enzyme inhibitors, Carvedilol and Spironolactone on improving endothelial function. This study aimed to evaluate the effect of the combination of Spironolactone, Carvedilol, and Captopril on endothelial function in breast cancer patients. Materials and Methods: This study is a prospective Randomized Clinical Trial in breast cancer patients who underwent chemotherapy. Patients were divided into two groups who received the combination of Captopril, Spironolactone, and Carvedilol or standard regimen for 3 months during chemotherapy. Before and after intervention, ejection fraction (EF), E/A ratio and e' and flow-mediated dilation (FMD) properties were calculated and then compared. Results: Fifty-eight patients with a mean age of 47.57 ± 9.46 years were evaluated. The mean FMD after the intervention is statistically different in case and controls (<0.001). E/A ratio and e' are not statistically different between groups after intervention. The mean EF was not statistically different between the two groups after intervention. Conclusion: Prescribing combination of Carvedilol, Spironolactone, and Captopril in breast cancer patients undergoing chemotherapy can improve endothelial function and may have beneficial effects on diastolic function.

Comparison of de novo implantation vs. upgrade cardiac resynchronisation therapy: a multicentre experience.

BACKGROUND: The clinical safety and consequences of upgrade procedures compared with de novo cardiac resynchronisation therapy (CRT) implantation in heart failure remain unclear. The present study aimed to assess clinical and procedural consequences of patients undergoing CRT upgrade as compared to de novo CRT implantations. METHODS: In this prospective cohort study, two subgroups were considered as the study population as (1) de novo group that CRT was considered on optimised medical treatment with heart failure of NYHA functional class from II to IV, left ventricular ejection fraction (LVEF) of ≤35%, and QRS width of >130 ms and (2) upgrade group including the patients with previously implantable cardioverter defibrillator (ICD) with the indications for upgrading to CRT. The two groups were compared regarding the changes in clinical outcome and echocardiography parameters. RESULTS: The procedure was successful in 95.9% of patients who underwent CRT upgrade and 100% of those who underwent de novo CRT implantation. It showed a significant improvement in LVEF, severity of mitral regurgitation and NYHA functional classification, without any difference between the two study groups. Overall procedural related complications were reported in 10.8% and 3.8% (p = .093) and cardiac death in 5.4% and 2.5% (p = .360), respectively, with no overall difference in postoperative outcome between the two groups. CONCLUSIONS: Upgrading to CRT is a safe and effective procedure regarding improvement of functional class, left ventricular function status and post-procedural outcome.

Thrombotic Events and Anticoagulants in Beta-thalassemia Patients with Focus on Anticoagulants for Atrial Fibrillation: A Brief Review.

Despite many advances in the diagnosis and treatment of beta-thalassemia patients in recent years and their longevity and quality of life which has been greatly increased, many of these patients have other life-threatening risks. The prevalence of atrial fibrillation in beta-thalassemia patients and its related thromboembolism, stroke, and mortality have been increased in the last few years. Appropriate anticoagulant therapy may help to prevent the incidence or recurrence of thromboembolism. So far warfarin is the most widely used drug. Aspirin should use with caution in these patients because of its resistance to aspirin over time, which can increase the risk of thromboembolism. Direct oral anticoagulants (DOACs) are widely used to prevent embolism in coronary artery disease and venous thromboembolism, but their use in thalassemia patients is still very limited. More high-quality researches and clinical trials are needed to prove their effectiveness and safety for atrial fibrillation in beta-thalassemia patients.

Anethum graveolens L. (Dill) Effect on Human Lipid Profile: An Updated Systematic Review.

Dill is an aromatic edible herb, belongs to the genus Anethum in the celery family (Apiaceae or Umbelliferae) with a long history of cultivation from ancient times and two closely related cultivated species, European dill (Anethum graveolens) and Indian dill (Anethum Sowa). We wanted to do this systematic review on the effect of Anethum graveolens intake on lipid profile because the outcomes of multiple research and meta-analyses in this regard were inconsistent. A systematic search for English published randomized controlled trials (RCTs) covering PubMed, EMBASE, Scopus, and Coherence library. The pooled weighted mean difference (MD) and its 95% confidence interval (CI) were calculated and pooled using a random-effects model. Pooled data of 6 RCTs involving 171 intervention cases indicated that dill supplementation was associated with a significant reduction in mean serum total cholesterol (MD 95% CI= -3.71(-5.71,-1.70); P < 0.001), low-density lipoprotein cholesterol (LDL-C) (MD 95% CI= -1.51(-2.65,-0.47); P = 0.005), TG (triglycerides) (MD 95% CI= -2.48(-3.98,-0.98); P = 0.001) and interestingly high-density lipoprotein cholesterol level (HDL-C) (MD 95% CI= -2.19(-3.58,-0.81); P = 0.002). Subgroup analysis showed that dill use was more effective in lowering triglyceride in both hyperlipidemic patients, MD 95% CI= -3.54(-6.49,-0.60); P = 0.02) and type 2 diabetes (MD 95% CI= -3.64(-5.69,-1.58); P = 0.001). Dill use reduced the LDL levels more effectively in patients with type 2 diabetes (MD 95% CI= -3.54(-6.49,-0.60); P = 0.03). Dill supplementation significantly improved LDL-C, TG, and Total cholesterol (TC) levels but not HDL-C. Further high quality controlled clinical trials on human is needed for more accurate and confirm conclusion.

Presentation of COVID-19 infection with bizarre behavior and encephalopathy: a case report.

BACKGROUND: Current studies show that patients with severe coronavirus disease 2019 (COVID-19) have neurological symptoms manifesting as acute cerebrovascular diseases, impaired consciousness, and skeletal muscle symptoms. Bizarre behavior is an unusual and unique presenting symptom of COVID-19 infection in our patient. CASE PRESENTATION: We report a case of COVID-19 infection in a middle aged Iranian man without underlying disease who presented with bizarre behavior. Results of brain imaging were normal, but COVID-19 pneumonia was detected on chest computed tomography scan. Given the respiratory problem and positive polymerase chain reaction (PCR) test for COVID-19, treatment with hydroxychloroquine was administered, and after 2 days all of the symptoms resolved. CONCLUSIONS: Encephalopathy and encephalitis may be a possible presentation of COVID-19. Clinicians and health care providers should consider the presence of COVID-19 with bizarre behavior during this COVID-19 pandemic.