Steroid Use for Recovery of advanced atrioVentricular block Immediately after VALvular surgery (SURVIVAL): A preliminary randomized clinical trial.

BACKGROUND: Atrioventricular block (AVB) is an important complication following valvular surgery. Several factors including inflammation-mediated injury might trigger AVB. METHODS: Patients with advanced postoperative AVB were randomly assigned to receive either dexamethasone (0.4 mg/kg, maximum 30 mg/day) intravenously for 3 days or conservative care only. Primary endpoint was recovery rate in Day 5 since randomization. Secondary endpoints were recovery rate in Day 7 and Day 10, cumulative AVB time, permanent pacemaker (PPM) implantation rate, length of stay in critical care units, and postoperative major adverse events (MAE). RESULTS: We enrolled 139 subjects (48.9% male) with mean age of 59.9 years randomly allocated to intervention group (n = 69) and control group (n = 70). Dexamethasone led to higher recovery rates at Day 5 (82.6% vs. 62.9%, p = .009) and Day 7 (88.4% vs. 61.4%, p < .0001) respectively. This benefit ceased at Day 10 (83.05% vs. 78.6%, p = .547). Median cumulative AVB time was shorter in dexamethasone group compared with control group (41 h vs. 64 h, p = .044). PPM implantation rates were similar between the dexamethasone and control groups (15.9% vs. 17.1%, respectively, p = .849). Median length of stay in intensive care unit (ICU) (10 days vs. 12 days, p = .03) and MAE (17.4% vs. 25.7%, p = .133) tended to be lower with dexamethasone. CONCLUSION: Dexamethasone may serve as a safe and effective medication to help hasten recovery of advanced AVB after valvular surgery.

Impact of Baseline Estimated Glomerular Filtration Rate Using CKD-EPI Equation on Long-term Prognosis of STEMI Patients: A Matter of Small Increments!

BACKGROUND: Baseline biomarkers including glomerular filtration rate (GFR) guide the management of patients with ST-segment elevation myocardial infarction (STEMI). GFR is a tool for prediction of adverse outcomes in these patients. OBJECTIVES: We aimed to determine the prognostic utility of estimated GFR using Chronic Kidney Disease Epidemiology Collaboration in a cohort of STEMI patients. METHODS: A retrospective cohort was designed among 5953 patients with STEMI. Primary endpoint of the study was major adverse cardiovascular events. GFR was classified into 3 categories delineated as C1 (<60 mL/min), C2 (60-90), and C3 (≥ 90). RESULTS: Mean age of the patients was 60.38 ± 5.54 years and men constituted 78.8% of the study participants. After a median of 22 months, Multivariate Cox-regression demonstrated that hazards of major averse cardiovascular event, all-cause mortality, cardiovascular mortality, and nonfatal myocardial infarction were significantly lower for subjects in C3 as compared with those in C1. Corresponding hazard ratios (HRs) for mentioned outcomes regarding C3 versus C1 were (95% confidence interval) were (HR = 0.852 [0.656-0.975]; P = 0.035), (HR = 0.425 [0.250-0.725]; P = 0.002), (HR = 0.425 [0.242-0.749]; P = 0.003), and (0.885 [0.742-0.949]; P = 0.003), respectively. Normal GFR was also associated with declined in-hospital mortality with HR of C3 versus C1: 0.299 (0.178-0.504; P < 0.0001). CONCLUSIONS: Baseline GFR via Chronic Kidney Disease Epidemiology Collaboration is associated with long-term cardiovascular outcomes following STEMI.

ST-Segment-Elevation Myocardial Infarction Unmasking Underlying Systemic Lupus Erythematosus or Representing Thrombotic Thrombocytopenic Purpura? Report of a Challenging Case.

Thrombotic thrombocytopenic purpura (TTP) is a multisystem disorder that frequently manifests itself with renal and neurological involvements. Cardiac involvement, however, has been rarely reported. In this report, we present a rare case of acquired TTP with acute myocardial infarction (AMI) as the initial manifestation. Although AMI was successfully managed by percutaneous coronary intervention, the patient developed hemolytic anemia, fever, marked thrombocytopenia, oliguria, and renal dysfunction, requiring treatment with plasma exchange and corticosteroids. TTP, albeit extremely rare, should be considered in cases with unexpected thrombocytopenia during acute-phase treatment for AMI as it can be highly lethal if not treated immediately.

Is there an independent association between metabolic syndrome and smoking in Iranian adults? Results of a large multicenter national survey.

BACKGROUND: Theoretically, smoking status should be associated with metabolic syndrome. This relationship has not been studied in Iranian population so far. This study aimed to explore the association among cigarette smoking, metabolic syndrome (MetS) and its domains in a nationally representative sample of Iranians aged 25-64. METHODS: Information of participants regarding demographic data and smoking habits gathered through WHO STEPS questionnaires in the frame of fourth national surveillance of the risk factors of non-communicable diseases in 2011 across the country. The fasting plasma glucose, triglyceride level, high-density lipoprotein cholesterol (HDL-C) level, blood pressure, and anthropometric indices in each patient were measured. Data of 4000 subjects were analyzed with complex sample survey method. The prevalence of metabolic syndrome was assessed according to two definitions: International Diabetes Federation (IDF) and Iranian definition. RESULTS: Herein, 38.4% of smoker participants and 36.6% of non-smokers met the IDF criteria for MetS (P=0.67). Similarly, 31.1% of smokers and 34.1% of non-smokers had MetS according to Iranian-IDF (P=0.427). Only in univariate analysis, using IDF criteria female smokers had lower prevalence of MetS than non-smokers (13.9% vs. 36.5%, P=0.01). Multivariate analysis determined the following odds ratios for the association of smoking with MetS defined by IDF and Iranian-IDF criteria, respectively: OR= 0.89 (0.53-1.47), P=0.638 and OR= 0.97 (0.59-1.58), P=0.901. CONCLUSION: There was no significant association between smoking and MetS overall and among men. However, smoking was associated with lower prevalence of MetS among women.

Association between exposure to Efavirenz and substrates of dysrhythmia in HIV-infected young adults.

BACKGROUND: Dysrhythmia and sudden cardiac arrest occur more likely in HIV patients than healthy subjects. Thus, we need to examine dysrhythmias adverse effects of medications including Efavirenz as early as possible especially in young subjects. HYPOTHESIS: Efavirenz might have contributed to increased risk of developing common types of dysrhythmia in young HIV infected patients. METHODS: We performed a retrospective cohort study among 62 patients on Efavirenz and 38 controls. All participants were under 40 years old without cardiovascular disease. Total significant dysrhythmia in 24-hour ECG monitoring was the primary endpoint determined as the composite of high premature ventricular contraction (PVC) (>500 beats per 24 hours), high premature atrial contraction (PAC) (>500 bp24h), sinus pause, atrioventricular blocks, ventricular tachycardia, prolonged QTc, and low heart rate variability (HRV). Modified composite dysrhythmia consisted of low HRV (SD of normal-to-normal [SDNN]), high PVC and prolonged QT. RESULTS: Mean heart rate, Efavirenz regimen, male gender, and CD4 count predicted total dysrhythmia. Odds ratios were 1.108, 2.90, 4.36, and 0.96, respectively. The incidence of total dysrhythmia, high PVC, high PAC, low HRV(SDNN), and prolonged QTc were 54.8%, 41.85%, 9.71%, 45.2%, and 12.9% in patients on Efavirenz against 42.11%, 31.64%, 0%, 34.2%, and 7.91% in controls, respectively (p-values: .031, .001, <.0001, .063, and .043 respectively). Modified composite dysrhythmia was also more frequent in Efavirenz group than that of control group (69.42% vs. 52.60%, respectively p = .032). CONCLUSIONS: We found that patients with Efavirenz had higher prevalence of frequent PVC, frequent PAC, total significant dysrhythmia, Low HRV and prolonged QTc than controls.

Prognostic implications of calculated Apo-lipoprotein B in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: Outcome is tied to lower cut-points.

BACKGROUND: Debates still surround using lipoproteins including Apo-B in risk assessment, management, and prognosis of patients with coronary artery disease. During an acute ST-segment elevation myocardial infarction, Apo-B might help to achieve incremental prognostic information. OBJECTIVE: We sought to determine the potential prognostic utility of calculated Apo-B in a cohort of patients with STEMI undergoing primary PCI. METHODS: A retrospective cohort study was conducted enrolling 2,259 patients with a diagnosis of acute STEMI who underwent primary PCI. Apo-B was obtained using a valid equation based on initial lipid measurements. High Apo-B was defined as a level of 65 or higher. Primary endpoint of the study was major adverse cardiovascular events (MACE). RESULTS: Mean age of the participants was 59.54 years and 77.9% of them were male. After a Median follow up of 15 (6.2) months, high Apo-B was associated with MACE and the OR (95% CI) was 3.02 (1.07-8.47), p = .036. Odds ratios for prediction of MACE pertaining to LVEF, and smoking were 0.97 (p = .044), and 1.07 (p = .033), respectively. However, High Apo-B was not able to predict suboptimal TIMI flow. Accordingly, the Odds ratio was 0.56 (0.17-1.87), p = 0.349. The power of High LDL-C and Non-HDLC for prediction of MACE were assessed in distinct models. Attained odds ratios were [2.40 (0.90-6.36), p = .077] and [1.80 (0.75-4.35), p = 0.191], respectively. CONCLUSION: Calculated Apo-B appears to be a simple tool applicable for prediction of cardiovascular events in patients with STEMI superior to both Non-HDLC and LDL-C.

Incidence and predictors of chronic thromboembolic pulmonary hypertension following first episode of acute pulmonary embolism.

INTRODUCTION: Late obstructive pulmonary artery remodeling presented as CTEPH portends adverse sequelae and therapeutic challenges. Although progressive dyspnea on exertion beyond three-month period of treatment with anticoagulants is a diagnostic cornerstone, uncertainty still surrounds early identification and risk factors. MATERIAL AND METHODS: We have conducted a prospective study among survivors of acute pulmonary embolism (PE) who were treated by anticoagulants for at least 3 months. Patients with preexisting pulmonary hypertension (PH), severe chronic obstructive pulmonary disease (COPD), and low ejection fraction (EF) in baseline echocardiography (EF < 30%) were excluded. Complete follow-up for 290 subjects were performed. According to a predetermined stepwise diagnostic protocol, patients with exertional Dyspnea and PH probable features in echocardiography underwent lung perfusion scan. RESULTS: Cumulative two-year incidence of CTEPH was 8.6% (n = 25). There was no patient with normal baseline right ventricular (RV) function in CTEPH group. In the same way, none of these patients had only segmental involvement in baseline CT angiography (CTA) in CTEPH group. Greater proportion of CTEPH group received fibrinolytic therapy, however the difference was not significant (2.6% vs 8 %, P = 0.16). Multivariate logistic regression demonstrated significant association of RV diameter, and PAP in baseline echocardiography as well as RV strain in CTA with development of CTEPH. Corresponding odds ratios were 1.147 (1.063-1.584) P < 0.0001) , 1.062 (1.019-1.106, P = 0.004), and 2.537 (1.041-6.674), P = 0.027), respectively. CONCLUSIONS: We found that incidence of CTEPH was relatively high in the present investigation. RV diameter, baseline PAP and RV dysfunction were independent predictors of CTEPH.

One-Year Outcome of Patients with Coronary Artery Ectasia Undergoing Percutaneous Coronary Intervention: Clinical Implications and Question Marks.

Background: Coronary artery ectasia (CAE) is a rare condition with unclear pathophysiology, optimal treatment, and prognosis. We aimed to determine the prognostic implications of CAE following coronary angioplasty. Methods: We conducted a retrospective cohort study on 385 patients, including 87 subjects with CAE, who underwent percutaneous coronary intervention (PCI). Major adverse cardiovascular events (MACE) were considered to consist of mortality, nonfatal myocardial infarction (MI), repeated revascularization, and stroke. Results: The mean age of the participants was 57.31±6.70 years. Multivariate regression analysis revealed that patients with diabetes, ST-segment-elevation MI at presentation, and high thrombus grades were more likely to have suboptimal post-PCI thrombolysis in myocardial infarction (TIMI) flow. However, CAE was not a predictor of a decreased TIMI flow (OR: 1.46, 95% CI: 0.78-8.32; P=0.391). The Cox-regression model showed that CAE, the body mass index, and a family history of MI were risk factors for MACE, while short lesion lengths (<20 vs >20 mm) had an inverse relationship. The adjusted hazard ratio (HR) for the prediction of MACE in the presence of CAE was 1.65 (95% CI: 1.08-4.78; P=0.391). All-cause mortality (HR: 1.69, 95% CI: 0.12-3.81; P=0.830) and nonfatal MI (HR: 1.03, 95% CI: 0.72-4.21; P=0.341) occurred similarly in the CAE and non-CAE groups. Conversely, CAE increased urgent repeat revascularization (HR: 2.40; 95% CI: 1.13-5.86; P=0.013). Conclusion: Although CAE had no substantial short-term prognostic effects on post-PCI TIMI flow, considerable concerns regarding adverse outcomes emerged during our extended follow-up. Stringent follow-ups of these patients should be underscored due to the high likelihood of urgent revascularization.