hassan shemirani

Cerebral ischemia and coronary artery disease (CAD), the major leading causes of mortality and morbidity worldwide, are pathophysiologically interrelated. Cerebral ischemic events are categorized as large or small vessels disease. The current study compares the factors related to CAD events incidence following ischemic large versus small disease CVA. The current cohort study was conducted on 225 patients with ischemic stroke in two groups of large (n=75) and small (n=150) vessel disease during 2018-19. The patients’ demographic, medical, and clinical characteristics were recruited. They were followed for three years regarding the incidence of CAD events, including ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), unstable angina (UA), and sudden cardiac death (SCD). Data about the coronary angiography, computed tomography angiography (CTA), Single Photon Emission Computed Tomography (SPECT), and the therapeutic approach were gathered. There were insignificant differences between the patients with small versus large vessels CVA in terms of ACS incidence (P-value=0.105), type of the events (P-value=0.836), angiographic (P-value=0.671), SPECT (P-value=0.99) and CTA findings (P-value>0.99) and approached CAD (P-value=0.728). Cox regression assessments revealed an increased risk of CAD events due to large versus small vessels disease after adjustments for hypertension, diabetes mellitus, dyslipidemia, re-stroke, and the previous history of IHD (HR=2.005, 95%CI: 1.093-2.988, P-value=0.021). According to the findings of this study, large-vessel involvement in an ischemic stroke was associated with more than a two-fold increase in the three-year probability of ischemic heart disease incidencet.

The aims of this study were to determine the prognosis in heart infarction patients who were also suffering from COVID-19 disease and its relationship with underlying diseases and blood factors and the severity of pulmonary involvement.

This cross-sectional descriptive study extracted data from the medical records of patients hospitalized in Alzahra, Chamran, and Khorsheed hospitals in Isfahan city from 2020 to 2021. Individuals over 18 years old diagnosed with myocardial infarction and positive polymerase chain reaction (PCR) test placed under angiography were included in the study. Variables studied included age, gender, comorbidities, medications, smoking history, vaccination status, laboratory findings, echocardiography, angiography, and mortality. Logistic regression analysis was used to analyze the data.

A total of 65 patients were examined. The most common comorbidity was hypertension (55.4%) and the most common symptom was chest pain (84.6%). Left ventricular ejection fraction decreased (38.2%), and this decrease was significant in patients with ST-elevation myocardial infarction (33.5% vs. 43.7%, P = 0.0009). Thrombosis was observed in 14 patients, which was more common in the ST-elevation myocardial infarction (STEMI) group than in the non-ST-elevation myocardial infarction (NSTEMI) group (30.8% vs. 7.7%, P = 0.03). The most involved artery was LAD (60%). There was no significant association between the severity of COVID-19 and myocardial infarction subtypes. Moreover, these subgroups did not show a significant association with mortality rates.

No significant association was found between the severity of COVID-19 and myocardial infarction subtypes in our study.

One of the important criteria for acute myocardial ischemia is the level of troponin. The fact that troponin is excreted by the kidneys, and patients under dialysis may have a high level of it, makes the diagnosis of acute ischemia difficult. The present study aimed to evaluate the effect of hemodialysis on serum troponin I level in patients with end-stage renal disease (ESRD) and normal left ventricular ejection fraction (LVEF).

In this cross-sectional study, 106 patients with ESRD and LVEF of more than 50% who underwent hemodialysis during 2018-2019 in Khorshid and Alzahra hospitals in Isfahan, Iran, were studied. The serum levels of troponin I were measured and compared before and after hemodialysis. -

The mean serum level of troponin I was 0.031 ± 0.068 and 0.028 ± 0.036 ng/dl before and after hemodialysis, respectively, with no statistically difference (P = 0.590). The mean difference of troponin level before and after the hemodialysis was 0.003 ± 0.06 ng/ml. Moreover, the changes of troponin levels were not significantly associated with age, sex, duration of dialysis, hemoglobin and hematocrit levels, LVEF, cause of renal failure, and type of underlying disease.

The findings of the present study showed that hemodialysis did not have a significant effect on changes in troponin I levels, and the level of troponin I did not appear to be a suitable biomarker for the expression of cardiovascular disease in hemodialysis patients with normal LVEF.

Acute myocardial ischemia during coronavirus disease 2019 (COVID-19) infection can occur in two forms of acute myocardial infarction type І and II. In acute myocardial infarction type І, infection can cause inflammation, and inflammation causes the secretion and increase of cytokines such as interleukin 1, 6, and 8, as well as tumor necrosis factor (TNF) in the circulation. This mechanism causes the secretion of collagenase from activated macrophages, and the results of these reactions is a precursor to plaque rupture, increased coagulation, and thrombus formation. This mechanism causes acute myocardial infarction type І on atherosclerotic plaque. In these patients, primary percutaneous coronary intervention (PCI) is the treatment of choice, contrary to the initial theory that lytic therapy was the main treatment. In COVID conditions, the primary PCI time increases from 120 minutes to 180 minutes, and if the primary PCI takes more than 180 minutes, then lytic therapy is recommended. In acute myocardial infarction type II, patients usually do not have angina clinically, troponin rises slightly (less than 2 times normal), and do not have electrocardiogram changes as a sign of ischemia. However, patients with coronary heart disease have persistent chest pain with or without myocardial necrosis. During COVID-19 infection, due to release of interleukin, tumor necrosis alpha, and catecholamine, as well as hypoxia, acidosis, hypertension and/or hypotension, oxygen delivery and myocardial oxygen demand become disturbed, so acute myocardial infarction type II may occur. Supportive therapies are performed in these patients, and the treatment of acute underlying disease such as treatment with steroidal anti-inflammatory drugs and antiviral drugs is the main treatment.</div>

Recently, the relationship between increased level of inflammatory mediators and occurrence of left ventricular failure in patients with kidney disease has been suggested. The present study attempted to assess relationship between inflammatory mediators and occurrence of left ventricular failure in patients with chronic kidney disease.

This cross‑sectional study was performed at Noor and Hazrat Aliasghar hospital in Isfahan between September 2012 to September 2013 on patients aged >19 years that referred for following their chronic kidney disease. Serum level of inflammatory parameters including C‑reactive protein (CRP) and Interleukin‑6 (IL‑6) was measured using spectrophotometer. All patients were also assessed using M‑mode echocardiography to determine left ventricular ejection fraction (LVEF).

The group with significant reduced LVEF showed lower GFR when compared to the normal LVEF group (40.73 ± 20.61% versus 44.43 ± 17.98%, P = 0.032). Comparing GFR across the three groups with normal LVEF (>55%), with mild LV dysfunction (LVEF: 45 – 55) those with significant LV dysfunction (LVEF < 45%) showed significantly lower GFR level in latter group compared with normal LVEF and mild LV dysfunction group (P = 0.026). Although the level of serum CRP was significantly higher in patients with significant left ventricular failure than other groups (P = 0.018).

Inflammatory processes can potentially affect left ventricular function in patients with chronic kidney disease. In this regard, increased level of CRP may be a main factor for predicting severity of left ventricular failure in these patients.

No-reflow phenomenon after percutaneous coronary intervention (PCI) in patients with acute ST-segment-elevation myocardial infarction (STEMI) is relatively common and has therapeutic and prognostic implications. On the other hand cigarette smoking is known to be deleterious in patients with coronary artery disease, but the effect of smoking on no-reflow phenomenon is less investigated. The aim of our study was to assess the impact of smoking on no-reflow phenomenon after PCI in STEMI patients. A total number of 141 patients who were admitted to Chamran Hospital (Isfahan, Iran) between March and September, 2012 with diagnosis of STEMI, enrolled into our Cohort study. Patients were divided into current smoker and non-smoker groups (based on patient’s information). All patients underwent primary PCI or rescue PCI Within the first 12 hours of chest pain. No-reflow phenomenon, thrombolysis in myocardial infarction (TIMI) flow and 24-hour complications were assessed in both groups. 47 current smoker cases (32.9%) and 94 (65.7%) nonsmoker cases were evaluated. Smokers in comparison to non-smokers were younger (53.47 ± 10.59 versus 61.46 ± 10.55, P-value <0.001) and they were less likely to be hypertensive (15.2% versus 44.7%, P-value< 0.001), diabetic (17% versus 36.2%, P-value <0.05), and female gender (4.3% versus 25.5%, P-value <0.01). Angiographic and procedural characteristics of both groups were similar. 9 patients died during the first 24 hours after PCI (4.3% of smokers and 6.4% of non-smokers, P-value: 0.72). No-reflow phenomenon was observed in 29.8% of current smokers and 31.5% of non-smokers (P-value = 0.77). Smoking status and no-reflow phenomenon were not significantly correlated even after adjustments for age, gender, history of diabetes, hypertension, history of CAD and the extent of stenosis (OR = 1.68; 95% CI 0.68-4.10, P-value = 0.25). According to the present study, no-reflow phenomenon or short-term complications were not significantly lower in smokers. So better results in previous studies may be explained by differences in baseline characteristics and not by smoking status itself. Current smokers developed STEMI about 8 years earlier than non-smokers with similar age and sex-adjusted risk of no-reflow phenomenon and 24 hour mortality. These results emphasize role of efforts to encourage smoking cessation as prevention of myocardial infarction.

Methadone is a synthetic opioid, which has been successfully used in treating heroin addiction and chronic pain syndrome in palliative care for more than 30 years. This drug is a potent blocker of the delayed rectifier potassium ion channel, which may result in corrected QT (QTc) interval prolongation and increased risk of torsades de pointes (TdP) in susceptible individuals.CASE REPORT: We describe here a case of methadone-induced TdP that deteriorated into ventricular fibrillation, which was resolved after treatment with IV magnesium, potassium, and Lidocaine. Our purpose in this case review was to highlight the risk of cardiac arrhythmias, in particular QTc interval prolongation leading to TdP in a heroin-dependent patient receiving methadone substitution therapy, and then to present a perspective on treatment and prevention strategies of methadone induced prolonged QTc. Methadone-induced TdP is a potentially fatal complication of methadone therapy. As the popularity of methadone use grows, clinicians will encounter more cases of methadone induced TdP, especially in our region, Iran. Hence, a thorough patient history and electrocardiogram monitoring are essential for patients treated with this agent, and alterations in treatment options may be necessary.

Primary percutaneous coronary intervention (PPCI) is the preferred treatment method for ST elevation myocardial infarction (STEMI). However, the required equipments are not available in all hospitals. Thus, due to shortage of time, some patients receive thrombolysis therapy first. Patients with chest pain and/or persistent ST segment elevation will then undergo rescue percutaneous coronary intervention (PCI). The present study evaluated and compared the frequency of no-reflow phenomenon and 24-hour complications after PCI among patients who underwent PPCI or rescue PCI. This cross-sectional study assessed no-reflow phenomenon, 24-hour complications, and thrombolysis in myocardial infarction (TIMI) flow in patients admitted to Chamran Hospital (Isfahan, Iran) with a diagnosis of STEMI during March-September, 2011. Subjects underwent PPCI if they had received eptifibatide. Rescue PCI was performed if patients had chest pain and/or persistent ST segment elevation despite receiving streptokinase (SK). Demographic characteristics, history of diseases, medicine, angiography findings, PCI type, and complications during the first 24 hours following PCI were collected. Data was then analyzed by Student’s t-test, chi-square test, and logistic regression analysis. A total number of 143 individuals, including 67 PPCI cases (46.9%) and 76 cases of rescue PCI (53.1%), were evaluated. The mean age of the participants was 58.92 ± 11.16 years old. Females constituted 18.2% (n = 26) of the whole population. No-reflow phenomenon was observed in 51 subjects (37.1%). Although 9 patients (6.3%) died during the first 24 hours after PCI, neither the crude nor the model adjusted for age and gender revealed significant relations between rescue PCI and death or no-reflow phenomenon. Rescue PCI and no-reflow phenomenon were not significantly correlated even after adjustments for age, gender, history of diabetes, hypertension, hyperlipidemia, coronary artery disease, smoking, platelets number, myocardial infarction level, the extent of stenosis, and the involved artery. According to the present study, although SK is more effective than eptifibatide in resolution of thrombosis and clots, rescue PCI did not differ from PPCI in terms of the incidence of no-reflow phenomenon or short-term complications.

Reperfusion therapy is the standard treatment of acute myocardial infarction (AMI). If the percutaneous coronary intervention (PCI), as a preferred reperfusion strategy, is not available, thrombolytic therapy would be chosen as an alternative treatment. However, the effect of thrombolytic therapy on old patients is still controversial especially due to its effects on increasing the incidence of intracranial hemorrhage (ICH). In this study, we evaluated the incidence of neurological symptoms and ICH after thrombolytic therapy in AMI patients over 65 years of age. A total number of 300 AMI patients over 65 years of age who referred to the hospital within 12 hours of their symptom onset and had no contraindications for receiving thrombolytic therapy were selected. The patients were admitted in Noor Hospital, Isfahan, Iran, between 2004 and 2006. All of them received streptokinase (SK) in the same way. Their information was extracted from their files and collected by a questionnaire.. Among 300 patients in our study, there were 124 women (41.33%) and 176men (58.66%). Their mean age was 74 ± 9 years (range: 65-92 years). Moreover, 78% were discharged after one week of hospitalization and 22% (66 patients) died. Arrhythmias or myocardial reinfarction were the leading cause of death in 56.06% of all deaths. No death due to ICH and no evidence of ICH, such as hemiparesis or loss of consciousness, were observed. We suggest that thrombolytic therapy in old patients with AMI is a good alternative treatment when there is no access to an equipped PCI facility. In our study, the increase in mortality rate due to ICH was not high enough to prevent us from prescribing SK for AMI patients over 65 years of age.

Antistreptokinase antibody in serum of people who had been exposed to streptococcal infections may interfere with thrombolytic effects of streptokinase. Streptokinase is the only thrombolytic medication in Iran, and is the first line treatment in myocardial infection. Considering the high prevalence of streptococcal infections in Iran as compared to developed countries, the high levels of serum antibody might neutralize streptokinase. Serum levels of antistreptokinase antibody of 126 people with myocardial infarction who went to Noor Hospital in Isfahan, Iran were measured before administrating streptokinase. The effects of the drug were then evaluated and compared by considering the consequent echocardiographic (ECG) changes during hospitalization. In 17 out of 126 patients (13.5%), the antibody levels were high and the drug did not have any effects. This number is 2.5 times more than the values in references. In 25 patients, among whom 3 had high levels of antistreptokinase antibody, the drug was effective. Considering the lack of relationship between high levels of antistreptokinase antibody and the efficacy of streptokinase in patients with myocardial infarction in this study, studies with larger sample size and more objective criteria, such as serum fibrinogen as the indicator of streptokinase efficacy, are recommended.

Epicardial fat tissue is known as a risk factor in cardiovascular diseases. This study was designed to compare the epicardial fat thickness in patients with cardiovascular diseases and normal patients. It also tried to find a correlation between epicardial fat thickness and severity of coronary stenosis. This study was conducted from September 2010 to April 2011 at two university hospitals (Noor and Chamran Referral centers) associated to Isfahan University of Medical Sciences, Isfahan, Iran. A total number of 196 subjects were allocate to three groups of control (n = 68), acute coronary syndrome (n = 64) and chronic stable angina (n = 64). After registering demographic data, all individuals underwent echocardiography in diastolic subcostal view to determine the epicardial fat thickness. Angiography was also conducted to assess the severity of coronary stenosis. The thickness of epicardial fat was compared between groups and its correlations with age, sex, hypertension, hypercholesterolemia, diabetes, waist circumference, body mass index and severity of coronary stenosis were evaluated. The mean age of participants was 59.54 ± 11.01 years. There were statistical differences between age, sex, smoking and severity of coronary stenosis (P < 0.001, P = 0.03, P = 0.04, and P < 0.001, respectively). The mean of epicardial fat thickness in acute coronary syndrome, chronic stable angina and control groups were 5.7 ± 2.1, 6.2 ± 2.0 and 4.6 ± 1.9 mm (P < 0.001). There were no independent correlation between predicting factors and epicardial fat thickness (P > 0.05). This study indicated the thickness of epicardial fat to be more in cardiovascular diseases compared with normal persons. Future studies for evaluating the sensitivity and specificity of this diagnostic method are warranted.

Studies of the association between the plasma concentration of lipoprotein (a) and coronary heart disease (CHD) have reported apparently conflicting finding. The objective of the present study is to evaluate the association between serum levels of LP (a) and ischemic heart disease as well as other cardiovascular risk factors in a population – based study conducted on local cross sectional. LP (a) serum was measured in 142 patients with chronic stable angina who were under going clinically indicated coronary angiography. Lipid profilefasting blood glucose, anthropometric and clinical parameters were analyzed. LP (a) levels were significantly associated with numbers of coronary artery stenosis (CAD) in men, but no in women. Also, an direct association between mean levels of LP (a) and number of CAD in men younger than 55 years old inverse association in men older than 55years old were observed. Our multivariate analysis found that LP (a) was considered an independent predictor for severity of CHD in men, especially in younger individuals.

Reperfusion therapy is the standard treatment of acute myocardial infarction (AMI). If the percutaneous coronary intervention (PCI), as a preferred reperfusion strategy, was not available, thrombolytic therapy is chosen as an alternative treatment. However, the affect of thrombolytic therapy in old patients is still controversial; especially because of its effects on increasing the incidence of intra cranial hemorrhage (ICH). In this study, we evaluated the incidence of neurological symptoms and ICH after thrombolytic therapy in more than 65 years old patients with AMI.

300 patients of 65 years old and more with AMI in which their symptoms had been begun more than 12 hours before admission to the hospital, and with no contraindications for receiving thrombolytic therapy, were chosen. The patients were admitted in Noor hospital between 2004 and 2006. All of them received streptokinase (SK) in the same way, and the information's were pulled out from their files and gathered in a check list.

Among 300 patients in our study, there were 124 women (41/33%) and 176 men (58/66%). Their mean age was (74±9) years (from 65 to 92 years). 78% were discharged after one week hospitalization and 22% (66 patients) died. Arrhythmias or myocardial re-infarction were the leading cause of death in 56/06% of all deaths. No death due to ICH and no evidence of ICH, such as hemi-paresis or loss of consciousness, were occurred.

We suggest that thrombolytic therapy in old patients with acute myocardial infarction is a good alternative treatment when there is no ready access to a skilled PCI facility.In our study, increasing of mortality rate due to ICH was not enough to exclude giving SK to more than 65 years old patients.