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Background: Atrial Flutter (AFL) and Atrial Fibrillation (AF) are among the most common supraventricular tachyarrhythmias. Sometimes, differentiation of the two arrhythmias using surface electrocardiography becomes difficult. Objectives: This study aimed to compare the Left Atrial Appendage (LAA) ejection flow waves of AFL and AF to determine whether it can serve as a method for differentiating the two arrhythmias. Methods: This cross-sectional study was conducted on 20 patients with AF and 20 ones with AFL selected via simple sampling method. During Trans-Esophageal Echocardiography (TEE), pulsed Doppler sampling was laid 1 cm inside the LAA and pattern of LAA ejection flow waves was recorded in terms of rate (number per minute), velocity (centimeter per second), and regularity. The two groups were compared using Mann-Whitney U-test. P ≤ 0.05 was considered to be statistically significant. Results: The rate of LAA ejection flow waves was 493.75 ± 50.57 in the AF group and 303.50 ± 16.31 in the AFL group (P < 0.001). Besides, the mean velocity was 0.172 ± 0.069 m/s in the AF group and 0.302 ± 0.106 m/s in the AFL group (P < 0.001). Velocity more than 0.17 m/s had a sensitivity of 95.0% (95% CI, 75.1 - 99.2%), specificity of 70.0% (95% CI, 45.7 - 88.0%), positive predictive value of 76.0%, and negative predictive value of 93.03% for diagnosing AFL. All patients in the AF group had irregular patterns, but all those in the AFL group had regular patterns. Conclusion: Since TEE is a usual part for evaluation of patients suspected to have AF or AFL, it may be helpful for differentiating AFL from AF by examining LAA ejection flow waves. [ABSTRACT FROM AUTHOR]

Introduction: Various epidemiological studies have shown the relationship between increased risk of atherosclerosis and cardiovascular diseases (CAD) on the one hand and poor control of blood sugar and lipid profile on the other hand. Furthermore, it has been shown that substitution of saturated fatty acids with polyunsaturated fatty acids (PUFAs) and α linolenic acid (ALA) would improve glucose homeostasis. Material and methods: One hundred diabetic patients were assigned to the experiment and control groups randomly. For the experiment group, walnut oil (15 g/day for three months) was added to the diet, while the control group did not undergo any interventions. Before initiation of the experiment and after the end of the experiment, the systolic and diastolic blood pressure (SBP and DBP) levels of the patients were measured and recorded. Also, weight and height of the patients were recorded, and a blood sample was taken for measurement of fasting blood sugar (FBS) and HbA1c and using paired t-test and t-test for analysis. Results: The results demonstrated that HbA1c and FBS levels decreased significantly in the experiment group (p = 0.032 and p = 0.029, respectively). However, the two groups were not significantly different in terms of SBP (p = 0.103), DBP (p = 0.687), body weight (p = 0.202), and BMI (p = 0.416). Conclusions: Consumption of walnut oil (15 g/day for three months) improved blood glucose homeostasis in type 2 diabetic patients. Because no changes in the bodyweight and blood pressure of the patients were seen, it could be used in hypertensive or obese patients. [ABSTRACT FROM AUTHOR]

Background: Both Transthoracic Echocardiography (TTE) and Transesophgeal Echocardiography (TEE) are effective investigation tools to detect cardioaortic sources of embolism in ischemic stroke. Nevertheless, there are still uncertainties about the cost-effectiveness of these methods in non-selected patients with acute stroke. Objectives: This study aimed to investigate the cost-effectiveness of TTE and TEE using a decision analytic model in non-selected patients with acute ischemic stroke with or without clinical and radiological signs of embolic pattern. Patients and Methods: This cross-sectional cost-effectiveness study was performed in Nemazee hospital affiliated to Shiraz University of Medical Sciences from January 2014 to April 2014. TTE and TEE were performed for all 65 consecutive patients with ischemic stroke (51.3% male, mean age of 69.7 ± 17.9 years). The required data were direct costs related to performance of TTE and TEE, which were obtained from the patients' bills in their charts. A decision analytic model was implemented to assess the cost-effectiveness of these two methods, which demonstrated an Incremental Cost-Effectiveness Ratio (ICER). Effectiveness was determined based on the number of disorders diagnosed using each of the two echoes confirmed by two cardiologists. All analyses were done using Tree Age Pro 2011. Results: The results showed that TEE was more expensive than TTE in non-selected patients. Performing TEE increased the cost by 1494 USD and the effectiveness by 7%. As per ICER equation, for each increment unit in the effectiveness, performing TEE would increase the cost by 213.4 USD compared to TTE. TEE was cost-effective in comparison to TTE regardless of age factor considering the cutoff of Gross Domestic Product (GDP) by three for ICER. Moreover, TTE was cost-effective in 41-60- and 61-80-year-old age groups, while TEE was cost-effective in the 41-60-year-old age group. However, none of the techniques was cost-effective in patients above 81 years old. Conclusions: The results of this study can help reduce the unnecessary use of echocardiography by considering the age group and their corresponding risk factors for developing ischemic stroke. [ABSTRACT FROM AUTHOR]

Background: Statin treatment can cause elevation of the liver aminotransferase levels in 1-3% of the patients with hypercholesterolemia. Previous studies indicate that vitamin E plays a role in declining the increased levels of liver enzymes caused by fatty liver disease. Objectives: We conducted this study to determine the effect of vitamin E on liver aminotransferase levels in patients with elevated aminotransferase levels due to statin consumption. Materials and Methods: This study was a randomized, double-blind, placebo-controlled trials. Eligible patients were those who developed elevated aminotransferase levels after initiation of statin. They were randomized into the intervention group (vitamin E capsules, 400 units/day for one month) and placebo group. Randomization was done with permuted block sampling method with a 2:1 enrolment ratio. Study capsules were allocated in separate packs blinded and labeled using a four-digit code. Alanine aminotransferase (ALT) and asparate aminotransferase (AST) levels were checked in the beginning and one month after the intervention. Comparison of the levels before and after the intervention was done by paired sample T-test, and between group difference was checked by independent sample T-test. Results: A final number of 23 patients enrolled in this study (15 in the intervention and 8 in the control parallel groups). Baseline ALT and AST levels in both groups showed no difference (74.3 ± 9.1 vs. 77.6 ± 17.5, P = 0.9; and 50 ± 8.2 vs. 43.3 ± 9.3, P = 0.34, respectively). With consumption of vitamin E, ALT level was decreased from 77.6 ± 17.5 to 40.9 ± 13.4, showing a significant difference with placebo (treatment difference = -25.7, P = 0.04). However, the reduction of asparate aminotransferase level from 43.3 ± 9.3 to 29.8 ± 5.9 was not significant compared to placebo (treatment difference = -1.5, P = 0.12). Conclusions: Vitamin E therapy in patients with moderately elevated aminotransferase levels (1.5-3 times than basal levels) due to statin consumption may be beneficial and can reduce the asymptomatic hepatocellular damages. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objectives: In cirrhotic patients, despite presence of significant metabolic abnormalities and enlarged left atria, we have seldom observed atrial fibrillation (AF) rhythm. The aim of this study was to evaluate the prevalence of AF among cirrhotic patients and comparing it with that reported in the general population. Materials and Methods: Medical documents of 1302 adult cirrhotic patients, booked in the waiting list of liver transplantation, were evaluated retrospectively. Electrocardiograms were reviewed for the presence of AF rhythm, and echocardiographies were reviewed to obtain left atrial (LA) size. Result: Only two patients (0.15%) were detected to have AF rhythm, which was significantly lower than that reported in our general population, even after age and sex adjustment. Six hundred and sixty-eight patients (51%) had enlarged left atria (LA diameter more than 39mm); both AF patients belonged to this group. Conclusion: The result of this study suggests the protective effect of liver cirrhosis on development of atrial fibrillation. Further studies are needed to verify the possible mechanisms. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which discussed a study aimed at determining the differences of some characters of patent foramen ovale (PFO) in patients with ischemic stroke where PFO was associated with another major cause of stroke and those with PFOs as the primary cause of ischemic stroke.

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. [ABSTRACT FROM PUBLISHER]

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. [ABSTRACT FROM AUTHOR]

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.

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.

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.

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.

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.