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Abstract Objectives Using the cardiac surgery database is of high importance in referral centers and can lead to a better quality of care for patients. Tehran Heart Center (THC) is a cardiovascular referral center that was inaugurated in 2001. In this report, we aimed to present the third report of trends in patients' cardiovascular risk factors and surgical procedures from 2002 to 2021 that have been gathered for all THC patients. Methods This serial cross-sectional study was conducted at Tehran Heart Center from 2002 to 2021. All patients undergoing cardiac surgeries were eligible to enter the study (N = 63,974). Those with miscellaneous types of surgeries were excluded (N = 9556). The distribution of cardiac surgeries (including isolated coronary artery bypass graft (CABG), isolated valve, and CABG + valve surgeries) and their respective in-hospital mortality were recorded. Furthermore, 20-year trends in the prevalence of various cardiovascular risk factors (CVRFs) among the following groups were evaluated: a) isolated CABG, b) aortic valve replacement/repair for aortic stenosis (AS/AVR/r), and c) isolated other valve surgeries (IVS). Results A total of 54,418 patients (male: 70.7%, age: 62.7 ± 10.8 years) comprised the final study population, with 84.5% prevalence of isolated CABG. Overall, the AS/AVR/r group was in between the CABG and IVS groups concerning CVRFs distribution. Excluding some exceptions for the AS/AVR/r group (in which the small sample size (N = 909) precluded observing a clear trend), all studied CVRFs demonstrated an overall rising trend from 2002 to 2021 in all three groups. Regarding in-hospital mortality, the highest rate was recorded as 4.0% in 2020, while the lowest rate was 2.0% in 2001. Conclusions Isolated CABG remained the most frequent procedure in THC. Notable, increasing trends in CVRFs were observed during this 20-year period and across various types of cardiac surgeries, which highlights the clinical and policy-making implications of our findings. Graphical Abstract

Abstract Background High-density lipoprotein cholesterol (HDL-C) is shown to be an independent protective factor against coronary artery diseases (CAD). Yet there are limited studies focusing on the association between HDL-C and coronary artery bypass graft (CABG) surgery outcomes. Hypothesis Low levels of HDL-C are associated with higher incidence of adverse outcomes in patients undergoing CABG. Methods This registry-based study included 17,772 patients who underwent elective isolated CABG between 2007 and 2017. Patients were classified into low and desirable HDL-C groups based on their serum HDL-C levels at admission and were followed for one-year post-surgery. The study population included 13,321 patients with low HDL-C and 4,451 with desirable HDL-C. proportional hazard Cox models were performed to evaluate the association between HDL-C levels and incidence of mortality as well as major adverse cardiovascular and cerebrovascular events (MACCE), while adjusting for potential confounders. Moreover, participants were stratified based on sex and the association was also investigated in each subgroup separately. Results No significant difference was found between the groups regarding incidence of both mortality and MACCE, after adjusting with Inverse Probability Weighting (IPW) [HR (95%CI): 0.84 (0.46–1.53), p-value:0.575 and HR (95% CI): 0.91 (0.56–1.50), p-value:0.733, respectively]. According to the sex-based subgroup analysis, no significant association was observed after adjustment with IPW analysis. However, as we examined the association between the interaction of HDL-C levels, sex and cardiovascular outcomes, we found a significant association (HR;1.19 (95%CI: 1.04–1.45); p = 0.030). Conclusion HDL-C level was not associated with either mortality or MACCE during one year after CABG procedure. Sex-based analysis showed that in males, HDL-C is significantly more protective against these outcomes, compared to females. Further studies are necessary to elucidate the exact mechanisms mediating such association.

Abstract Background The diagnosis of vasovagal syncope (VVS) is mainly based on history-taking and physical examination. However, brain Magnetic Resonance Imaging (MRI) and Electroencephalogram (EEG) are commonly used in the diagnostic course of VVS, despite not being indicated in the guidelines. This study aims to find the possible associated factors with the administration of brain MRI and EEG in patients with VVS. Methods Patients with a diagnosis of VVS from 2017 to 2022 were included. Several demographic and syncope features were recorded. The association of these was assessed with undergoing MRI, EEG, and either MRI or EEG. Univariate and multivariable logistic regression models were also used to calculate odds ratios (OR) and 95% confidence intervals (CI). Results A total of 1882 patients with VVS were analyzed, among which 810 underwent MRI (43.04%), 985 underwent EEG (52.34%), and 1166 underwent MRI or EEG (61.96%). Head trauma (OR 1.38, 95% CI 1.06 to 1.80), previous neurologist visit (OR 6.28, 95% CI 4.24 to 9.64), and gaze disturbance during syncope (OR 1.75, 95% CI 1.13 to 2.78) were all positively associated to the performance of brain MRI/EEG. Similar results were found for urinary incontinence (OR 2.415, 95% CI 1.494 to 4.055), amnesia (OR 1.421, 95% CI 1.053 to 1.930), headache after syncope (OR 1.321, 95% CI 1.046 to 1.672), and tonic-clonic movements in head-up tilt table test (OR 1.501, 95% CI 1.087 to 2.093). However, male sex (OR 0.655, 95% CI 0.535 to 0.800) and chest pain before syncope (OR 0.628, 95% CI 0.459 to 0.860) had significant negative associations with performing brain MRI/EEG. Conclusion Based on our findings, performing MRI or EEG was common among VVS patients while it is not indicated in the majority of cases. This should be taken into consideration to prevent inappropriate MRI/EEG when there is a typical history compatible with VVS.

Abstract Background Although several studies are available regarding baseline Electrocardiographic (ECG) parameters and major and minor ECG abnormalities, there is considerable controversy regarding their age and gender differences in the literature. Methods Data from 7630 adults aged ≥ 35 from the Tehran Cohort Study registered between March 2016 and March 2019 were collected. Basic ECG parameters values and abnormalities related to arrhythmia, defined according to the American Heart Association definitions, were analyzed and compared between genders and four distinct age groups. The odds ratio of having any major ECG abnormality between men and women, stratified by age, was calculated. Results The average age was 53.6 (± 12.66), and women made up 54.2% (n = 4132) of subjects. The average heart rate (HR) was higher among women(p

Abstract Introduction Tobacco use is a major health concern worldwide, especially in low/middle-income countries. We aimed to assess the prevalence of cigarette smoking, waterpipe, and pipe use in Tehran, Iran. Methods We used data from 8272 participants of the Tehran Cohort Study recruitment phase. Tobacco use was defined as a positive answer to using cigarettes, waterpipes, or pipes. Participants who did not report tobacco use during the interview but had a previous smoking history were categorized as former users. Age- and sex-weighted prevalence rates were calculated based on the national census data, and characteristics of current and former tobacco users were analyzed. Results Age- and sex-weighted prevalence of current tobacco users, cigarette smokers, waterpipe, and pipe users in Tehran was 19.8%, 14.9%, 6.1%, and 0.5%, respectively. Current tobacco use was higher in younger individuals (35–45 years: 23.4% vs. ≥ 75 years: 10.4%, P 12 years: 19.3% vs. illiterate: 9.7%, P

AimA considerable proportion of patients admitted with acute coronary syndrome (ACS) have no standard modifiable cardiovascular risk factors (SMuRFs: hypertension, diabetes mellitus, dyslipidemia, and cigarette smoking). The outcomes of this population following percutaneous coronary intervention (PCI) are debated. Further, sex differences within this population have yet to be established.MethodsThis retrospective cohort study included 7,847 patients with ACS who underwent PCI. The study outcomes were in-hospital mortality, all-cause mortality, and major adverse cardio-cerebrovascular events (MACCE). The association between the absence of SMuRFs (SMuRF-less status) and outcomes among all the patients and each sex was assessed using logistic and Cox proportional hazard regressions.ResultsApproximately 11% of the study population had none of the SMuRFs. During 12.13 [11.99–12.36] months of follow-up, in-hospital mortality (adjusted-odds ratio (OR):1.51, 95%confidence interval (CI): 0.91–2.65, P:0.108), all-cause mortality [adjusted-hazard ratio (HR): 1.01, 95%CI: 0.88–1.46, P: 0.731], and MACCE (adjusted-HR: 0.93, 95%CI:0.81–1.12, P: 0.412) did not differ between patients with and without SMuRFs. Sex-stratified analyses recapitulated similar outcomes between SMuRF+ and SMuRF-less men. In contrast, SMuRF-less women had significantly higher in-hospital (adjusted-OR: 3.28, 95%CI: 1.92–6.21, P

Background: To define changes in AMI case rates, patient demographics, cardiovascular comorbidities, treatment approaches, in-hospital outcomes, and the economic burden of COVID-19 during the pandemic. Methods: We conducted a multicenter, observational survey with selected hospitals from three medical universities in Tehran city. A data collection tool consisting of three parts. The first part included socio-demographic information, and the second part included clinical information, major complications, and in-hospital mortality. Finally, the third part was related to the direct medical costs generated by AMI in COVID-19 and non-COVID-19 patients. The study cohort comprised 4,560 hospitalizations for AMI (2,935 for STEMI [64%] and 1,625 for NSTEMI [36%]). Results: Of those hospitalized for AMI, 1,864 (76.6 %) and 1,659 (78 %) were male before the COVID-19 outbreak and during the COVID-19 era, respectively. The length of stay (LOS), was significantly lower during the COVID-19 pandemic era (4.27 ± 3.63 vs 5.24 ± 5.17, p = 0.00). Results showed that there were no significant differences in terms of patient risk factors across periods. A total of 2,126 AMIs were registered during the COVID-19 era, with a 12.65 % reduction (95 % CI 1.5–25.1) compared with the equivalent time in 2019 (P = 0.179). The risk of in-hospital mortality rate for AMI patients increased from 4.9 % in 2019 to 7.0 % in the COVID-19 era (OR = 1.42; 95 % CI 1.11–1.82; P = 0.004). Major complications were registered in 9.7 % of cases in 2020, which is higher than the rate of 6.6 % reported in 2019 (OR = 1.46, 95 % CI 1.11–1.82; P = 0.000). Total costs in hospitalized AMI-COVID patients averaged $188 more than in AMI patients (P = 0.020). Conclusion: This cross-sectional study found important changes in AMI hospitalization rates, worse outcomes, and higher costs during the COVID-19 periods. Future studies are recommended to examine the long-term outcomes of hospitalized AMI patients during the COVID-19 era.

Abstract Background Despite the recognized implications of high-density lipoprotein cholesterol (HDL-C) in cardiovascular diseases, the role of body mass index (BMI) in HDL-C association with cardiovascular outcomes remains unclear. This study investigated the possible modifying implications of BMI on the correlation between HDL-C and coronary artery bypass grafting (CABG) outcomes. Methods The present cohort included isolated CABG patients (median follow-up: 76.58 [75.79–77.38] months). The participants were classified into three groups: 18.5 ≤ BMI

Abstract Objective In this study we aimed to compare on-pump and off-pump coronary artery bypass grafting (CABG) outcomes in patients presented with low left ventricular ejection fraction (EF) as a high-risk group of patients. Methods In this registry-based study from 2014 and 2016, all patients with severe left ventricular dysfunction (EF less than 35%) were included and followed until 2020. The median follow-up period was 47.83 [38.41, 55.19] months. Off pump CABG (OPCABG) was compared with on-pump CABG (ONCABG) in terms of mid-term non-fatal cardiovascular events (CVEs) and all-cause mortality. Propensity score method (with inverse probability weighting technique) was used to compare these two groups. Results From 14,237 patients who underwent isolated CABG, 2055 patients with EF ≤ 35% were included; 1705 in ONCABG and 350 patients in OPCABG groups. Although OPCABG was associated with lower risk of 30-days mortality (Odds Ratio [OR]: 0.021; Confidence Interval [CI] 95% [0.01, 0.05], P

Abstract Background Recent research suggests a protective role for positive family history of premature cardiovascular disease (FHpCVD) in patients undergoing coronary artery bypass grafting. We aimed to further investigate this unlikely association. Methods In this registry-based cohort study, patients who underwent first-time non-emergent coronary bypass surgery at Tehran Heart Center between 2007 and 2016 were included. Patients with and without FHpCVD were compared in terms of all-cause mortality and first non-fatal cardiovascular events (CVEs) comprising non-fatal acute coronary syndrome, non-fatal stroke or transient ischemic attack, and repeat coronary revascularization. Results A total of 13,156 patients were included (mean age 60.83 ± 9.57, 74.5% male), among which 2684 (20.4%) patients had FHpCVD. Median follow-up was 77.7 months. FHpCVD was weakly associated with reduced all-cause mortality using inverse probability weight (IPW) method (hazard ratio [HR] = 0.853; 95% confidence interval [CI] 0.730–0.997; P = 0.046), and not associated with non-fatal CVEs considering death as the competing event (sub-distribution HR [SHR] = 1.124; 95% CI 0.999–1.265; P = 0.053). Within a subgroup of patients without previous myocardial infarction or revascularization (7403 cases; 56.3%), FHpCVD was associated with lower mortality (HR = 0.700; 95% CI 0.548–0.894; P = 0.004) and higher non-fatal CVEs (SHR = 1.197; 95% CI 1.019–1.405; P = 0.028), whereas among patients with previous coronary events, there was no association between FHpCVD and outcomes. Conclusions FHpCVD was associated with lower all-cause mortality but higher non-fatal CVEs, especially in those without prior coronary events. Such discordance calls for caution in assuming a protective role for FHpCVD. The prognostic significance of FHpCVD needs further evaluation among surgical patients.

Background Recent research has revealed that vasovagal syncope (VVS) leads to a high incidence of injuries; however, clinical associations of injury are not well‐established. We present data from an ongoing VVS cohort and aimed to determine characteristics associated with VVS‐related injury. Methods and Results Between 2017 and 2020, consecutive patients ≥18 years of age presenting to a tertiary syncope unit and diagnosed with VVS were included. Clinical characteristics relevant to syncope were obtained for the index episode. The outcome was incidence of injury during VVS, documented by clinical evaluation at the syncope clinic. Among 1115 patients (mean age, 45.9 years; 48% women), 260 injuries (23%) occurred. History of VVS‐related injuries (adjusted relative risk [aRR], 1.80 [95% CI, 1.42–2.29]), standing position (aRR, 1.34 [95% CI, 1.06–1.68]), and female sex (aRR, 1.30 [95% CI, 1.06–1.60]) were associated with injury, whereas recurrent VVS (aRR, 0.63 [95% CI, 0.49–0.81]) and syncope in the noon/afternoon (aRR, 0.70 [95% CI, 0.56–0.87]) and evening/night (aRR, 0.43 [95% CI, 0.33–0.57]) compared with morning hours were associated with lower risk. There was a trend for higher rates of injury with overweight/obesity (aRR, 1.23 [95% CI, 0.99–1.54]) and syncope occurring at home (aRR, 1.22 [95% CI, 0.98–1.51]). In a per‐syncope analysis considering up to 3 previous episodes (n=2518, 36% traumatic), syncope at home (aRR, 1.33 [95% CI, 1.17–1.51]) and absence of prodromes (aRR, 1.34 [95% CI, 1.09–1.61]) were associated with injury. Conclusions Patient characteristics, VVS presentations, the circumstances, and surroundings can determine the risk of injury. These associations of VVS‐related injury identify at‐risk individuals and high‐risk situations. Future prospective studies are needed to investigate potential strategies for prevention of post‐VVS injury in recurrent cases.

Background: To assess the cost-effectiveness of sacubitril/valsartan compared with enalapril in patients with heart failure with reduced ejection (HFrEF). Methods: A systematic literature search was conducted searching in major electronic databases from inception to January 1, 2021. All relevant full economic evaluation studies of sacubitril/valsartan versus enalapril for the treatment of patients with HFrEF were identified using ad hoc search strategies. Mortality, hospital admissions, quality-adjusted life years (QALYs), life-years (LYQs), annual drug costs, total lifetime costs, and incremental cost-effectiveness ratio (ICER) were considered as the outcomes. The quality of the included studies was assessed using the CHEERS checklist. This study was conducted and reported in accordance with the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses” (PRISMA) guidelines. Results: The initial search yielded a pool of 1026 articles, of which 703 unique articles were screened, 65 full-text articles were assessed for eligibility and 15 studies finally included in the qualitative synthesis. Studies show that sacubitril/valsartan reduces mortality and hospitalization rate. The mean of death risk ratio and hospitalization were computed at 0.843 and 0.844, respectively. Sacubitril/valsartan produced higher annual and total lifetime costs. The lowest and highest lifetime costs for sacubitril/valsartan were found in Thailand ($4,756) and Germany ($118,815), respectively. The lowest ICER was reported in Thailand ($4857/QALY) and the highest in the USA ($143,891/QALY). Conclusion: Sacubitril/valsartan is associated with better outcomes and may be cost-effective compared to enalapril for the management of HFrEF. However, in developing countries such as Thailand, sacubitril-valsartan costs must be reduced to yield an ICER below the threshold.

Abstract Background Despite several studies comparing off- and on-pump coronary artery bypass grafting (CABG), the effectiveness and outcomes of off-pump CABG still remain uncertain. Methods In this registry-based study, we assessed 8163 patients who underwent isolated CABG between 2014 and 2016. Propensity score matching (PSM), inverse probability of weighting (IPW) and covariate adjustment were performed to correct for and minimize selection bias. Results The overall mean age of the patients was 62 years, and 25.7% were women. Patients who underwent off-pump CABG had shorter length of hospitalization (p

Since the SARS-CoV-2 pandemic began, numerous studies have reported a concerning drop in the number of acute myocardial infarction (AMI) admissions. In the present systematic review and meta-analysis, we aimed to compare the rate of AMI admissions and major complication during the pandemic, in comparison with pre-pandemic periods. Three major databases (PubMed, Scopus, and Web of Science Core Collection) were searched. Out of 314 articles, 41 were entered into the study. Patients hospitalized for AMI were 35% less in the COVID-19 era compared with pre-pandemic periods, which was statistically significantly (OR = 0.65; 95% CI: 0.56–0.74; I2 = 99%; p

Abstract Introduction Heart failure (HF) is an unusual heart function that causes reduction in cardiac or pulmonary output. Cardiac resynchronization therapy (CRT) is a mechanical device that helps to recover ventricular dysfunction by pacing the ventricles. This study planned to systematically review cost-effectiveness of CRT combined with an implantable cardioverter-defibrillator (ICD) versus ICD in patients with HF. Methods We used five databases (NHS Economic Evaluation Database, Cochrane Library, Medline, PubMed, and Scopus) to systematically reviewed studies published in the English language on the cost-effectiveness of CRT with defibrillator (CRT-D) Vs. ICD in patients with HF over 2000 to 2020. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was applied to assess the quality of the selected studies. Results Five studies reporting the cost-effectiveness of CRT-D vs ICD were finally identified. The results revealed that time horizon, direct medical costs, type of model, discount rate, and sensitivity analysis obviously mentioned in almost all studies. All studies used quality-adjusted life years (QALYs) as an effectiveness measurement. The highest and the lowest Incremental cost-effectiveness ratio (ICER) were reported in the USA ($138,649per QALY) and the UK ($41,787per QALY), respectively. Conclusion Result of the study showed that CRT-D compared to ICD alone was the most cost-effective treatment in patients with HF.

Objective: A permanent pacemaker (PPM) is necessary for patients with a symptomatic third-degree or advanced second-degree atrioventricular (AV) block. An AV block due to medication use can often be reversed; however, subsequent relapse can occur and necessitate subsequent PPM implantation. The aim of this study was to explore the course and prognosis of patients with an AV block. Methods: This historical cohort study was conducted between January 2013 and June 2018. A total of 1900 patient records were analyzed and 1123 subjects with an AV block on admission were enrolled. The patients were categorized into 2 groups: Group 1 comprised patients with an AV block due to medication use (n=316, 28%) and Group 2 included patients with an AV block caused by other etiologies (n=807, 72%). Data of the cause of AV block, recurrence, and PPM implantation were analyzed. Patients in both groups who did not require a PPM during the index admission were followed up regarding subsequent implantation of a PPM. Results: AV conduction was recovered in 38 (12%) patients in Group 1 and 48 (6%) patients in Group 2 during the index hospitalization. However, recurrence of the AV block was observed in 18% of Group 1 patients and 40% of Group 2 patients. Only 25 patients in each group (4.5% of the whole study population) remained PPM-free during a median 3-year follow-up period. Conclusion: The study findings suggest that drug-induced AV blocks may not be as benign as previously thought. The high relapse rate indicates that watchful follow-up may be required despite discontinuation of the responsible medication and that consideration of earlier PPM implantation in cases of early recurrence may be warranted.

Cardiovascular disease, mental health, and injury are among the top health issues globally. In Tehran Cohort Study, we aimed to determine the prevalence, incidence, and trend of cardiovascular diseases, psychiatric symptoms, injury, and risk factors in Tehran households. We enrolled 4215 households in the recruitment phase from March 2016 to March 2019. Demographic characteristics, past medical history, medications, and familial history of the participants were collected. Rose angina pectoris, general health Questionnaire-28 (GHQ-28), and injury questionnaires were completed. Fasting blood samples were collected to measure routine biochemistry and store samples in the biobank. Anthropometric and physiological measurements and electrocardiograms were performed. The participants are followed every three years for up to 12 years. In total, 8296 individuals participated in the cardiovascular section, 10247 completed the GHQ-28, and 4167 households completed the injury questionnaire. The mean age of the participants was 48.2 (16.41), and 46.5% were male. 64.3% of recruited individuals had no symptoms of psychiatric disorders, and 3729 (89.5%) households did not have any severe injury requiring treatment. The participants' diversity and their invaluable data will help us provide a general picture of the current prevalence and incidence of the main study objectives.

Objective: The pathophysiology of coronary slow flow phenomenon (CSFP) is poorly understood. Evidence suggesting endothelial dysfunction in patients with slow coronary flow (SCF) led to this evaluation of a possible correlation between microalbuminuria (MAU), as an indicator of endothelial dysfunction, and CSFP in order to investigate a mutual pathophysiology. Methods: In this case-control study, 15786 patients who presented between September 2016 and April 2018 were screened. All patients with CSFP had chest pain and coronary angiography was indicated due to a positive noninvasive test. All cases had a Thrombosis in Myocardial Infarction (TIMI) flow grade of 2 or a corrected TIMI frame count of >27 without any evidence of obstructive coronary artery disease. The patients used as controls had completely normal coronary angiograms. Fasting mid-stream urine samples were analyzed using an immunoturbidimetric assay to determine the albumin-creatinine ratio (ACR) as a surrogate of microalbuminuria (MAU) (ACR: 30–300 mg/g). The prevalence of MAU in the case and control groups was analyzed. Results: A total of 154 individuals with a normal coronary angiogram and 46 patients with SCF were enrolled in the study. The prevalence of MAU was greater in patients with SCF than in the control group (8.7% vs 1.9%, respectively; p=0.048). Even after adjustment for major risk factors, the association between MAU and CSPF remained significant. Conclusion: The results of this study indicated that there was a relationship between MAU and CSFP and confirmed that endothelial dysfunction is a contributing factor to CSFP. These findings are of utmost importance due to the prognostic value of MAU for both all-cause and cardiovascular mortality rates.

Introduction: Some studies have demonstrated that post-PCI elevated cardiac enzymes are associated with worse outcomes. In this study, we aimed to determine if high-dose treatment with atorvastatin before planned elective PCI reduces PMI or MACE at 1-year median follow-up. Material and methods: Eligible participants were randomly allocated to group A (80 mg atorvastatin 12 h and 40 mg 2 h before PCI) and group B (40 mg atorvastatin daily). Blood samples were obtained before and at 24 h after PCI to measure hsTnT. All patients were followed regarding MACE (combination of death, re-hospitalizations for ACS, and unplanned coronary revascularization) during one year after PCI. Results: 207 patients randomly assigned to Group A (n = 97) or group B (n = 110). The rate of PMI was lower in group A (5.2%) compared to group B (10.9%); despite near to 50% lower rate of PMI in group A, binary logistic regression showed no significant association between atorvastatin recapture and PMI. The occurrence of MACE in 97 patients of group A was 11 (11.3%), higher than 11 (10%) cases of 110 patients in group B. Cox proportional hazards regression model shows no significant difference in MACE of study groups. Conclusion: Pretreatment of patients with stable angina who were planned to undergo an elective PCI with 120 mg of atorvastatin before the procedure confer them the same benefit in terms of PMI and MACE as 40 mg routine daily dosage of this statin does. Keywords: High dose atorvastatin, Elective percutaneous coronary intervention, Highly sensitive troponin T

Background: Despite the reduced quality of life in patients with recurrent vasovagal syncope (VVS), pharmacologic treatment options remain limited. Studies indicate that norepinephrine reuptake inhibition reduces tilt-induced syncope/pre-syncope. This study aimed to evaluate the effects of atomoxetine on syncopal/pre-syncopal episodes in patients with recurrent VVS. Methods: In a placebo-controlled trial, we randomized patients with newly diagnosed VVS who experienced ≥3 syncopal episodes in the past three months to receive either atomoxetine (20 mg daily for two weeks followed by 40 mg daily for two weeks) or placebo. The primary endpoint was the combined number of syncopal and pre-syncopal episodes. Results: Among 843 patients initially screened, 46 were randomized (N = 23 in each group) and reevaluated at one and three months. Compared to placebo, atomoxetine significantly reduced the primary endpoint after three months (P

Abstract: The aim of this systematic review and meta-analysis is to investigate the diagnostic accuracy of Computed Tomography Angiography (CTA) in comparison with that of Single-photon emission computed tomography (SPECT) for the diagnosis of Coronary Artery Disease (CAD) in patients with chest pain who have no prior history of cardiovascular diseases Invasive coronary angiography was considered as the reference test. Method: Cochrane, Scopus, Science Direct, Pubmed and Embase databases were searched. Meta-analysis was performed for determination of pooling estimates of sensitivity, specificity and positive and negative likelihood ratios in CTA and SPECT tests. Results: The pooled sensitivity and specificity of CTA were 91% (95% Confidence Interval [CI] 88%-94%) and 87% (95% CI 84%-98%), respectively. The pooled positive and negative likelihood ratios and the area under the Receiver Operating Characteristic (ROC) curve for CTA were 7.93 (95% CI 5.11-12.29), 0.1 (95% CI 0.06-0.17) and 0.96, respectively. The pooled sensitivity and specificity of SPECT were 81% (95% CI 79%-83%) and 74% (95% CI 71%-78%), respectively. The pooled positive and negative likelihood ratio sand the area under the ROC curve for SPECT were 3.03 (95% CI 2.34-3.91), 0.25 (95% CI 0.21-0.30) and 0.86, respectively. Conclusions: According to the results, the diagnostic accuracy of CTA and SPECT tests lie in the excellent and the very good ranges, respectively. CTA is a stronger evidence than SPECT to rule out cardiovascular diseases in patients with low to intermediate risks for CAD who had no prior history of cardiovascular diseases.

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 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.

Distinguishing ST-elevation myocardial infarction (STEMI) differential diagnoses is more challenging. Myopericarditis is one of these differentials that results from viral involvement of myocardium and pericardium of the heart. Myopericarditis in focal form can mimic acute STEMI in its electrocardiogram (ECG) features and elevated cardiac enzymes.Myocarditis patients may face thrombolytic related complications such as intracranial bleeding, myocardial rupture, and hemorrhagic cardiac tamponade. Furthermore, re-administration of streptokinase (a common thrombolytic agent in our country) is banned for at least six months of previous administration; however, it can save patients’ lives in emergency conditions such as massive pulmonary embolism. It seems that, when dealing with a young patient presenting to emergency department with acute chest pain and ST segment elevation on ECG, we should consider focal myocarditis as an important but rare differential diagnosis of STEMI. In this report, we describe three cases of focal myocarditis, primarily misdiagnosed as STEMI.

Inflammatory bowel disease (IBD) is a multisystem disorder with gastrointestinal tract involvement. These patients have the higher risk for thromboembolic events compared to normal population. This study describes a unique case of pulmonaryembolism as a first manifestation of inflammatory bowel disease.

Distinguishing ST-elevation myocardial infarction (STEMI) differential diagnoses is more challenging. Myopericarditis is one of these differentials that results from viral involvement of myocardium and pericardium of the heart. Myopericarditis in focal form can mimic acute STEMI in its electrocardiogram (ECG) features and elevated cardiac enzymes. Myocarditis patients may face thrombolytic related complications such as intracranial bleeding, myocardial rupture, and hemorrhagic cardiac tamponade. Furthermore, re-administration of streptokinase (a common thrombolytic agent in our country) is banned for at least six months of previous administration; however, it can save patients’ lives in emergency conditions such as massive pulmonary embolism. It seems that, when dealing with a young patient presenting to emergency department with acute chest pain and ST segment elevation on ECG, we should consider focal myocarditis as an important but rare differential diagnosis of STEMI. In this report, we describe three cases of focal myocarditis, primarily misdiagnosed as STEMI.

Inflammatory bowel disease (IBD) is a multisystem disorder with gastrointestinal tract involvement. These patients have the higher risk for thromboembolic events compared to normal population. This study describes a unique case of pulmonaryembolism as a first manifestation of inflammatory bowel disease.

BACKGROUND: Cardiac resynchronization therapy (CRT) is a medical device to help cardiac synchronized contractility by electrical impulses. Improvement of symptoms and left ventricular systolic function, reducing hospital admissions and mortality in patients with moderate to severe heart failure are the main benefits of administration of cardiac resynchronization therapy. CASE REPORT: In this article, we describe a case of heart failure and left bundle branch block (LBBB) who was candidate for cardiac resynchronization therapy; but after managing hyperkalemia, left bundle branch block resolved, ejection fraction increased and cardiac resynchronization therapy implantation was canceled. CONCLUSION: Exclusion of treatable causes is the first important step before any interventions. Now there is an important question; is cardiac resynchronization therapy effective in patients with heart failure and transient or intermittent left bundle branch block?

A majority of acute pericarditis cases have some degree of myocarditis. Viruses are the common etiological factor of this disease. Corticosteroids are considered for treatment, especially in recurrent models of the disease. In this article, we report the case of a 47-year-old man with myopericarditis who was under daily intra-muscular dexamethasone injection for an unknown reason. This is a unique case of spontaneous myopericarditis under corticosteroid abuse that has not been reported previously.

Hashimoto's encephalopathy (HE) is a rare condition characterized by atypical psychiatric and heterogeneous neurological manifestations such as acute cerebral ischemia, seizure, tremors, myoclonus, psychosis, depression, cognitive disorders, and fluctuating loss of consciousness. Here, a case of 28 year-old man was reported who referred to the emergency department (ED) with different acute neurologic disorders and final diagnose of HE.