مرتضی صافی

Diabetic Mellitus (DM) is a systemic disease that affects all body organs. Micro and macro vascular complications progress with diabetes progression. It is important to find a solution for early diagnosis of coronary artery disease that is a major cause of death in these patients. The goal of this study is to assess the relation between diabetic nephropathy and retinopathy to find coronary artery disease earlier and easier. Method of study: This study was done by cross-sectional method. All patients with diabetes mellitus studied for micro and macro vascular complications and coronary artery disease. Coronary angiography used for diagnosis of coronary artery disease. Diabetic retinopathy diagnosed with direct ophthalmoscopy by an ophthalmologist. Diagnosis of diabetic nephropathy was done by assessment of GFR with Cockcroft-Gault method or albuminuria in 24-hour urine collection. The prevalence of coronary artery disease and nephropathy and retinopathy determined in sample and the confidence interval was estimated. 104 patients with DM type 2 were studied. 68 (65.4%) patients had coronary artery disease. 54 (51.9%) patients had diabetic retinopathy and 40 (38.5%) had diabetic nephropathy. According to this study 47.1% patients, who had retinopathy and nephropathy at the same time had coronary artery disease as well. 23.5% of patients with retinopathy and 5.9% of patients with nephropathy had coronary artery disease. Coronary artery disease was seen in 23.5% of patient without any microvascular complications. It seems that microvascular complications consist of retinopathy and nephropathy have relation with coronary artery disease. Therefore, it seems simple evaluations such as blood and urine analysis or annual ophthalmic examinations by an ophthalmologist are simple and safe ways to follow diabetic patients and with early diagnosis we could intervene for early recognition of coronary artery disease.

The expansion of knowledge and information in different scientific branches necessitates the application of novel methods of educational management such as new methods of evaluation. Earlier studies on cardiovascular residency program in Iranian medical universities showed that little focus has been applied on novel teaching methods of ECG interpretation skills. This study was performed to investigate the effects of formative assessment and giving feedback on cardiovascular medical residents’ ECG interpretation skills in Shahid Beheshti University of Medical Sciences. In this quasi experimental study، twenty two 2nd and 3rd year cardiovascular medical residents of Modares and Talegani medical centers were investigated. Residents were randomly divided into two groups. After conducting pretest، all residents attended 20 weekly sessions on ECG interpretation. Then after 10 and 20 sessions they were reassessed (mid-test and post-test). Residents in case group received the answers of tests (ECG interpretation) while residents in control group did not receive any feedback on correct answers. At the end، the results of pre-test، mid-test، and post-test for two groups were compared using paired t test. Nine (49. 95%) residents were allocated in case group and 13 (59. 9%) in control group. Mean score of pretest in case and control croup were (42. 8±7. 3) and (41. 4±3. 7) respectively out of total score of 100 and no significant difference was observed between two groups at the beginning of study (P=0. 6). After 22 weeks، mean score of post-test reached to 94. 5±2. 4 in case group. This mean score reached to 82. 8±5. 5 for control group. Residents’ post-test mean scores improved in both groups compared to pretest. This improvement was significantly higher in case (feedback) group compared to control group (P<0. 001). The study showed that applying (continuous) formative assessment and giving feedback significantly improve ECG interpretation skills. Therefore we recommended using formative assessment and feedback as a part of educational and evaluative programs.

Conflicting data exist regarding the outcome of primary percutaneous coronary intervention, (PPCI) performed during the night hours. We sought to investigate this issue in a tertiary care center dealing with a high load of STEMI patients. Seventy three consecutive patients presenting with STEMI were divided in 2 groups with similar baseline characteristics. In-hospital mortality and morbidity during one month between March and April 2010 was analyzed between those treated with PPCI during normal-hours, (weekdays, 7AM to 7pm) vs. those in whom PPCI was done after normal working hours, (7pm to 7am). Mortality was 16.1% in normal-hours group and 4.8% in off-hours group (p<0.2); morbidity was 3.2% and 2.4% respectively (p<0.9) and angioplasty success was 100% in both groups. PPCI can be performed safely during the night.

Concerns about the known consequences of non adherence to standard treatment protocols by physicians in patients suffering from ACS and the lack of any dependable statistics as regards the degree of adherence in Iran and also the existence of different statistics on the subject in different countries led the present researchers to conduct an investigation to determine the extent of adherence to ACC/ AHA guidelines among cardiologists in patients with ACS. A cross sectional study was done in Shahid Modarres hospital in 2010. All patients suspected with ACS were investigated and those with definite diagnosis during angiography were included in the research. Their treatment protocols were investigated and the level of adherence to AHA guidelines was determined such that a ≥75% conformity with the guidelines was classified as complete adherence; 50% to 75% as relative adherence and <50% was classified as non adherence. K2 test was used in the analysis of data. Eighty-five patients with definite diagnosis of ACS were chosen out of 100 suspected patients. Complete adherence to the AHA protocol was noted in 47.1%, relative adherence in 32.9% and non adherence in 20%. In other words the level of adherence was unacceptable in 52.9%. No elements of individual characteristics and risk factors had any effect on the level of adherence (p<0.7). The high level of non adherence of the ACC/AHA guidelines in treatment of patients suffering from ACS is a cause of great concern. It is strongly recommended that a scientific investigation be carried out as the cause of this non adherence on the part of the cardiologists along with an investigation into the outcome of these patients.

Atherosclerotic Cardiovascular diseases are common and the rate is increasing. This study was planed to assess the prevalence of laboratory risk factors and associated parameters and categorize them. A cross–sectional study was done at prevention clinics of Modarres hospital in 1388-89; apparently healthy adults were invited for assessing cardiovascular risk factors. After obtaining informed consent 5 mL blood samples were collected from the participants after 12 hours fast and the level of LDL, HDL, Total Cholesterol, Triglyceride, Creatinine, CRP and FBS was measured at Modarres hospital laboratory. Abnormal levels were regarded as risk factors and reported. From 1047 participants, 48.2% were male. Mean age was 40.1 years. Most common laboratory risk factors were high LDL (51.2%) and then Low HDL (24.7%), high Triglyceride (22.5%) and high total cholesterol (19.8%). The least prevalent risk factors were high FBS (3.3%) and positive CRP (4.3%). Prevalence of cardio vascular risk factors and their order are changing rapidly and continuity of these studies in different societies is necessary.

In patients who undergo coronary angioplasty, Clopidogrel resistance is accompanied with increased risk of cardiovascular events (unstable angina, recurrent MI, death, etc). In different studies resistance to Clopidogrel has been reported to be up to 30%. Identification of these patients and determining the contributing factors can help us to reduce cardiovascular events. This cross-sectional study was carried out on candidates of elective percutaneous coronary intervention (PCI) in Shahid Modarres Hospital. Resistance to Clopidogrel was evaluated by platelet aggregometry in platelet-rich-plasma (PRP) using a routine aggregometer (Helena Biosciences Europe). The platelet aggregation was measured before and after exposure to 20 µ mol ADP as a reagent. Contributing factors such as age, gender, metabolic factors and medications were examined by Chi-square test. This study was run on 90 candidates for elective PCI. Their mean age was 62.6±10.2 years and 52.2% were male. 20% were semi-responder and 7.8% was non-responder. Gender, hypertension, obesity, using angiotensin-converting enzyme inhibitors and calcium channel blockers did not have any role in Clopidogrel resistance, but diabetes, hyperlipidemia, using beta blockers and statins were more common in Clopidogrel resistant patients (p<0.005). ‍ Considering both non-responders and semi-responders, prevalence of resistance to Clopidogrel was 27.8%, so we must be worried about it. Further larger studies should be designed to determine and manage the contributing factors.

Primary percutaneous angioplasty is a modality of choice to restore reperfusion in infarct related artery now. No-reflow phenomenon is a complication of this modality that increase mortality and morbidity of patients. Assessment of its associated and predictor factors may be useful to its prevention. All patients with ST elevation myocardial infarction (STEMI) who treated with primary percutaneous angioplasty during 30 months were enrolled to the study. Then patients with and without no-reflow phenomenon assigned to two groups and statistical analysis was performed. Twenty one cases of no-reflow were found in total 263 cases of primary PCI (7.9%). Mean age and prevalence of risk factors such as diabetes mellitus, smoking, hypertension and hyperlipidemia wasnt different in two groups. No- reflow was observed more frequently in females (P<0.01). Mean symptom to balloon time was longer in No-reflow group (P <0.01). Patients with no- reflow phenomenon have more cardiogenic shock, less predischarge ejection fraction, more inhaspital mortality, longer stent length, more LAD as infarct related artery and more use of thrombectomy(p value <0.05). There wasnt statistical significant in presence of collateral vessels, visible calcification, GP IIb/IIIa inhibitors usage, predilation, post dilation, and stent diameter (p value >0.05). The study demonstrated that female gender, LAD as infarct related artery, use of long stents and primary PCI in prolonged symptom to balloon time could be predictors of no- reflow phenomenon.

Myocardial infarction continues to be a major public health problem in many countries. Given the disparity of outcome in different studies and its importance, we evaluated the outcome of patients with ST segment elevated myocardial infarction (STEMI) and its influencing factors in Loghman hospital. This longitudinal study conducted between 2007-2008. All patients with STEMI admitted in Loghman hospital were included. The subjects were followed up for 30 days concerning their vitality status. TIMI risk score, demographic and clinical factors were also determined and their association with death was evaluated. Totally, 85 patients with a mean age of 58±14 years were evaluated, of whom 67% were males. Death occurred in 21.2%. Among died subjects, 77.8% had TIMI score of at least 8 when compared to 7.5% of alive patients (p<0.005). Sex, history of diabetes mellitus, smoking, angina and family history of coronary disease had no effect on mortality. Totally, 61% of patients who died didn’t receive streptokinase vs. 22.4% in alive subjects (p<0.005). Our measured survival rate is acceptable and TIMI risk score is a useful tool in predicting outcome of patients with STEMI.

Abstract Backgraound: Renal artery stenosis is a cause of secondary hypertension. Regarding known complication of this disease and possible positive effects of renal artery angioplasty on diastolic function, this study performed among patients with renal artery stenosis. This clinical trial, with before and after design, was performed on 35 eligible patients. Patients with renal artery stenosis (70% stenosis alone, or 50% stenosis with uncontrolled hypertension) which underwent stent– supported precutanous transluminal renal angioplasty (PTRA) were evaluated by Doppler echo and tissue Doppler before and six months after angioplasty. Isovolumic Relaxation Time (IVRT), Deceleration time (DT), E/A, E/Ea and diastolic function were studied. Data were analyzed by Wilcoxon test. 35 patients, including 11 male (31.4 percent) and 24 female (68.6 percent), with mean age (± standard deviation) of 59.6±10.2 years were studied. Renal artery angioplasty doesn’t affect on IVRT and E/A, but it decreased DT and E/Ea to 30.9±54.9 milliseconds (p< 0.002) and 0.44±0.9 (p< 0.04), respectively. It seems that renal artery angioplasty doesn’t alter type of diastolic function, but it decreases E/Ea, as a parameter representing diastolic function.

Early revascularization is the main step in treatment of patients with acute MI which since a few years ago has been done via P-PCI. Since thrombolytic therapy is performed as a standard method of therapy of acute MI in all centers not equipped with angiography and angioplasty systems, we decided to compare these two methods in the university centers in Iran. This prospective study was conducted on STEMI (ST Elevation MI) patients referred to emergency department of Shohadaye Tajrish and Shahid Modarres Hospitals, in Tehran, for early revascularization using thrombolytic therapy or Primary PCI. We compared these two methods of revascularization based on the effects on ejection fraction, ST-resolution and complications. 287 patients (144 in T.T group and 143 in P-PCI group) were enrolled in our study. There were no differences in ejection fraction between the two groups, but ST-resolution was significantly better in the P-PCI group (P< 0.001). The rate of complications was similar in both groups. It seems the P-PCI is more effective than T.T in patients with STEMI.

Despite impressive advances in diagnosis over the past decades, ST elevation myocardial infarction (STEMI) continues to be a major public health problem in the many countries. In majority of patients with some STEMI, changes can be documented when serial electrocardiography (ECG) are compared; however, many factors limit the ability of ECG to diagnose and localize myocardial infarction (MI). The aim of this study was to evaluate accuracy of ECG in diagnosis and localization of MI. This prospective study was conducted on patients with STEMI who were admitted in Modarress Hospital, in Tehran. All patients underwent electrocardiography and angiography. Then, findings of these two noninvasive and invasive diagnostic methods were described with two independent operators. 140 STEMI patients (80 patients with anterior and 60 patients with inferior MI) were enrolled in this study. Presence of complete right bundle branch block (CRBB) in ECG of patients with anterior MI had the least negative predictive value (NPV=69%). ST segment depression more than 1mm in lead d1 had the most positive predictive value (ppb=97%) for right coronary artery involvement. ST segment elevation in leads v5 & v6 had the least positive value (ppv= 81%) for LCX involvement. ST segment depression in inferior leads had the most negative predictive value (94%) for LAD involvement. In patents with STEMI, electrocardiography alone is not a good diagnostic method to diagnose and localize MI

Considering the increasing prevalence of patients with dyspnea and the possibility of heart disease, as well as unavailability of echocardiography specially in primary care situations and unreliability of echocardiography findings in some diseases and finding NT-ProBNP as a diagnostic factor in heart failure in these patients, this study was done to determine the accuracy of NT-ProBNP in comparison to echocardiography in the diagnosis of heart failure in Modarress Hospital, in Tehran, between 2006 and 2007. This study, with a clinical trial diagnostic design, was performed on patients with chief complaint of dyspnea. The NT-ProBNP marker of serum was determined by Elecsys and patients were categorized according to age adjusted reference book values into two groups of with and without heart failure. Then, the patients underwent Simpson Echocardiography and Tissue Doppler; and the positive and negative predictive value for NT-ProBNP in relation to the echocardiography was determined and analyzed by statistical tests. One hundred patients were analyzed. Mean age was 59±11.8 years and 70% were male. PPV was 84%, NPV was 70.4%, false positive was 16%, while false negative was 29.5%. Sensitivity was 78%, specificity 77%, and accuracy was equal to 78%. It seems that NT-ProBNP marker is a good test for screening patients with dyspnea and besides clinical criteria it has an acceptable diagnostic value. It would be good to perform other studies, using more precise laboratory methods and re-evaluation of cut point especially for Iranian patients considering factors other than age to obtain a rapid, easy, and cost-effective test in primary care.

Coronary artery disease (CAD) is the most common cause of mortality worldwide. The most frequent symptom of CAD is angina pectoris. The aim of this study was to compare scientific and applicable difference of two kinds of sublingual nitroglycerin, made by G. Pohl-Boskamp (Germany) and Zahravi (Iran) Pharmaceutical Companies on hemodynamic indices in coronary angiography. We evaluated left ventricular systolic pressure, left ventricular end diastolic pressure, aortic systolic, diastolic and mean pressures before and 5 min after consumption of two 0.4 mg sublingual nitroglycerin pearls made by Zahravi Company, and one 0.8 mg sublingual nitroglycerin pearl made by G. Pohl-Boskamp Company in 30 and 31 patients, respectively. Primary hemodynamic data did not show significant statistics differences (p>0.05). Both sublingual nitroglycerin pearls induced significant reduction of all hemodynamic indices (p<0.001), with no statistical difference in both groups (p>0.05). In this study we showed that Zahravi-made sublingual nitroglycerin pearl has similar hemodynamic effects in patients underwent coronary angiography as compared with the G. Pohl-Boskamp one.

Considering the and importance of formation of atrial Thrombus (AT) in patients who had developed atrial fibrilation (AF) and its early diagnosis, and with some regards to several reports on benefits of applying the D-Dimer test in such conditions, this study was carried out to detemine the accuracy and value of this test compared to the gold standard method of Trans-Esophageal Echocardiography (TEE) in patients referring to Modarres hospital. This clinical trial was performed on 73 patients whom were diagnosed as having AF. A more accurate method of TEE was applied to confirm if they had atrial thrombi. For determination of value of D-Dimer test in diagnosis of AT, 5 cc of blood was taken from any subjects. The results were regarded normal if the D-Dimer level was less than 500 ng/ml. Then positive and negative predictive values (PPV & NPV) were calculated as diagnostic measurments. Of the 73 subjects of this study (67% women versus 33% men) with mean age of 44.7±12 years old, there was 53.4% who had the history of Warfarin usage. According to the results of D-Dimer test, 33% had reached to positive levels, whereas 67% revealed to have no thrombus. The PPV of this test was calculated 48.6% and the NPV was 81.6%. Regarding the present condition of our patients and the excessive use of Warfarin among them and also probable failures of D-Dimer test, this test does not have the acceptible capability (particularly duringin these situations) in diagnosing AT.