mohammad ali akbarzadeh

Anticoagulation therapy is one of the most important strategies for preventing clot formation and subsequent stroke, with warfarin representing the most widely used oral anticoagulant. However, predicting the outcomes of warfarin administration poses a major challenge for physicians because of the narrow boundary between the therapeutic and toxic levels of warfarin. Clinical decision support systems (CDSSs) can be used as a tool to improve both adherence to clinical guidelines and transfer of evidence-based knowledge to daily clinical practice for dose adjustment, thereby helping reduce medical errors. The aim of this study was to develop a prototype CDSS for predicting warfarin doses according to computerized clinical guidelines.

This applied developmental study involving a qualitative design was conducted in two major steps.First, computer-interpretable guidelines were extracted from existing clinical guidelines as a workflow diagram for warfarin therapy and were subsequently evaluated by an expert panel. Second, a prototype CDSS was designed with PHP programming language and SQL database, and Nielson’s heuristic evaluation checklist was used for usability testing.

In the first step, the findings were presented in two main workflows and two sub-workflows. In the second step, a prototype CDSS was designed. The overall usability of the prototype was found to be at a "relatively acceptable" level, with a rating percentage of 92.09.

The usability evaluation results suggest that CDSSs similar to the one presented herein could serve as valuable clinical decision support tools for estimating warfarin dosage. These promising results call for further research aimed at exploring the feasibility of implementing such systems in clinical settings.

Chronic heart failure (CHF) patients are usually faced with reduced physical function, inappropriate sport tolerance and inability for daily activities. Studies showed that increasing serum hemoglobin (Hb) level in CHF can increase the maximum oxygen delivery and the consequent functional capacity. We aimed to assess this finding.

This single-arm clinical trial study was conducted on patients with CHF between March 2019 and 2020 in our hospital. In baseline, NYHA function class and 6-minute walking test (6MWT) were recorded. Persian standard version of health-related quality of life (Iranian-QoL) questionnaire and visual analogue scale (VAS) for fatigue were also administered to patients. After calculating the required dose of elemental iron, intravenous ferric carboxymaltose solution was infused in 1000 mg dosage for patients with hemoglobin level of more than 11 mg/dl (anemia) and in 500 mg dosage for patients with hemoglobin level of more than 14 mg/dl (without anemia). All the examinations were repeated after 12 weeks.

Eventually, 50 (20 male and 30 female) patients with a mean age of 58.88 ± 17.05 years underwent analysis. The mean distance in 6MWT was significantly increased from baseline (mean±SD change: 17±6m, p < 0.001). In addition, the mean fatigue and quality of life scores were significantly improved 12 weeks after treatment in comparison to the baseline (P<0.001).

a one-cycle treatment with intravenous ferric carboxymaltose can efficiently improve the functional capacity and quality of life in patients with chronic heart failure who suffer from iron deficiency, with and without anemia.

Preeclampsia is one of the challenging complications of pregnancy, of which little is known about its etiology and pathogenesis. Many studies have shown higher mean platelet volume (MPV) in preeclamptic patients. Vitamin D deficiency is in association with larger-size platelets. Thus, we aimed to determine the correlation of vitamin D with MPV in preeclamptic patients.

This prospective case–control study was conducted in two tertiary hospitals in Tehran, Iran. Overall, 85 preeclamptic pregnant women and 85 normotensive pregnant women were entered between 2017 and 2018. Serum vitamin D concentration (ng/ml) and MPV (femtoliter) were measured for all patients.

MPV was significantly higher in the cases compared to controls (10.59±1.08 vs 8.10±0.95, P=0.0001). In addition, serum vitamin D level in the preeclamptic group was significantly lower in compare to the control group (17.79±11.03 vs 30.24±12.49; P=0.0001). In multivariate logistic regression analysis, high age of mother (OR: 1.13; 95% CI: 1.01-1.27; P=0.03), low level of serum vitamin D (OR: 0.93; 95% CI: 0.87-0.99; P=0.02) and high MPV (OR: 8.83; 95% CI: 4.17-18.67; P=0.0001) were independent predictors of preeclampsia. Moreover, a correlation analysis revealed that vitamin D levels correlated negatively with MPV (r= -0.41, P<0.0001).

Low levels of vitamin D in preeclamptic pregnancy are associated with higher platelet activity and thrombosis. In fact, the increment of MPV level might be a potential pathway for adverse outcomes of pregnancy including preeclampsia in the context of vitamin D deficiency.

The coronavirus disease 2019 (COVID-19) pandemic has left many victims and caused many problems for the healthcare systems of different countries. Many COVID-19 patients have cardiovascular complications, which are detectable using echocardiography. This study aimed to determine the echocardiographic findings and their association with mortality in an intensive care unit (ICU)-admitted COVID-19 patients.

In this retrospective study, COVID-19 patients admitted to the ICU of four hospitals in Tehran, Iran, from April 2020 to March 2021 were recruited. Data were collected by the census method. We reviewed the medical records regarding demographic features, clinical history, laboratory results, and echocardiographic findings. Finally, variables were compared regarding disease outcomes at the end of hospitalization. We used the Chi-square test, Fisher’s exact test, independent-samples t-test, and logistic regression model to analyze the data.

This study showed that the mean age of 629 COVID-19 patients was 66.42±14.53 years. Overall, 56.8% of the patients were male. Multivariate regression analysis showed that age (OR=1.03; 95% CI: 1.01-1.05), left ventricular ejection fraction (OR=0.95; 95% CI: 0.92-0.98), and systolic pulmonary arterial pressure (OR=1.12; 95% CI: 1.06-1.18) were predictors of mortality.

Cardiovascular involvement is prevalent among critically ill COVID-19 patients. Among echocardiographic findings, EF and s-PAP were significantly associated with the disease outcomes.

Cardiogenic shock is a sudden complication that occurs in 5 to 10% of patients with acute myocardial infarction. According to statistics, mortality and morbidity from this event, despite all hospital care, are approximately 70-80%.

This study was conducted over three years (2012 to 2014) in 28 cases of acute myocardial infarction, which was complicated by cardiovascular shock, before or after admission. We compared the outcomes of patients according to the treatment strategy, thrombolytic therapy, primary percutaneous coronary intervention (PCI), or other medical stabilization. The 30-day follow-up was the first endpoint, and the 3-month follow up was the second endpoint of the study.

28 patients with cardiogenic shock included in this study. The mean (± SD) age of the patients was 62.99 ± 13.99 years. The median time to the onset of shock was 648.75 ± 1393.58 minutes after infarction. Most of the patients who underwent coronary angiography had 3-vessel or left main involvement. Two patients missed in follow up and five (80%) patients who received thrombolytic therapy passed away. Nine (100%) patients in the medical stabilization group and six patients (50%) underwent primary PCI group passed away too. The mortality in the primary PCI group was significantly lower than the other groups (P = 0.04)

Although cardiogenic shock is a potential risk of early death, it is important that the thrombolytic in these patients doesn't increase survival and the primary PCI is more effective than thrombolytic agents.

Given the fundamental role of platelet indices in the development of atherosclerotic plaque, these indices may play a predictive role for the occurrence of disturbed coronary reperfusion. The present study evaluated the association between platelet indices and coronary reperfusion status based on the Thrombolysis in Myocardial Infarction (TIMI) frame count.

This cross-sectional study was conducted on 98 consecutive patients with ST elevation myocardial infarction who were candidate for primary Percutaneous Coronary Intervention (PCI) at Modarres Hospital in Tehran between January 2016 and January 2018. Venous samples were extracted from all patients before primary PCI. To assess the condition of coronary reperfusion after primary PCI, the TIMI frame count related to culprit artery in acute myocardial infarction was determined.

The TIMI frame count was positively associated with platelet count (r = 0.320, P = 0.001) and more strongly with platelet to lymphocyte ratio (r = 0.375, P < 0.001), but not with other platelet indices such as platelet distribution width (PDW), mean platelet volume (MPV) or Platelet large cell ratio (PLCR). According to the ROC curve analysis, platelet to lymphocyte ratio was introduced as a valuable parameter for differentiating complete from disturbed reperfusion (AUC = 0.735, 95%CI: 0.613 – 0.858, P = 0.001). The best cutoff value for platelet to lymphocyte ratio in predicting disturbed reperfusion was 146.5 with a sensitivity of 81.8% and a specificity of 60.5%. However, other platelet indices could not present this predictive role.

The platelet to lymphocyte ratio with predictive accuracy and sensitivity predicts coronary perfusion impairment based on the increase in TIMI frame count.

cardiovascular diseases are the main cause of mortality around the whole world. However, there is limited information on its economic costs in Iran. The aim of this study was to evaluate the economic costs of coronary heart disease in Iran in 2014. The diseases costs were calculated based on the incidence approach using a bottom-up method and a community-oriented perspective. The drug cost information was obtained from angiographed patients (607 cases) in Shahid Modarres Hospital using simple random sampling method. Other information like disease incidence, distribution of patients, treatment patterns, length of stay and mortality rate was gathered from the literature, interview with patients, consultation with specialists, questionnaire, ministry of health and statistical center of Iran. Coronary heart diseases impose a significant economic burden in the range of 4,715 and 4,908 billion dollars (210,037,860,000,000-201,778,425,000,000 rials) upon Iran economic system. The medical costs and the costs of lost productivity due to premature death were calculated at USD 3.572 billion (152,863,740,000,000 rials) and USD 933 million (39,927,735,000,000 rials) respectively. The major part of medical costs was related to angioplasty costs (47%) and the minor part was related to drug costs (1.15%). Coronary heart diseases impose a lot of financial costs to Iran healthcare system which cover more than 16% of whole healthcare financial costs. It is possible to streamline all consequential costs due to coronary heart disease by means of economic and effective use of resources and widespread self-care plan.

Several complications can occur during electrophysiology (EP) study and radiofrequency catheter ablation (RFCA). In this study, we aimed to determine the frequency and types of complications following EP study and RF ablation in a tertiary cardiovascular center.
Between September 2012 and December 2012, patients undergoing RF ablation and EP studies were prospectively enrolled. Demographic and clinical data of the patients, as well as the underlying arrhythmia and indication for EP study, were recorded. Complications occurring during the procedure and admission period were documented.
A total of 382 procedures were performed in 357 patients with the mean age of 47 ± 18 years within the study period. The most common arrhythmia was atrioventricular nodal reentrant tachycardia (26.4%). Major complication happened in 10 (2.6%) procedures while minor complications occurred in 36 (9.4%) procedures. Tamponade was the most common major complication (n = 3 [0.7%]), and pericardial effusion was the most common minor complication (n = 19 [4.9%]). Patients with complication were significantly younger and had a lower ejection fraction (P = 0.003 and P = 0.02, respectively).
The complications observed in this study are comparable to previous reports, and EP study and RFCA can be considered as safe procedures.

A dual atrioventricular (AV) nodal response and His bundle extrasystole cannot be different in many cases with certainty. We present a 31-year-old man with episodes of palpitation and conducted and non-conducted His bundle extrasystole detected during an electrophysiology study.

Air pollution is one of the most important environmental health threats of our time worldwide, including Iran. Air pollution is a major risk factor threating public health. The overall aim of this study was to determine the relationship between air quality and the incidence of acute myocardial infarction in Tehran.
In this case crossover study, the association between Air Quality Index (AQI) of Tehran and the risk of developing ST-Elevation Myocardial Infarction (STEMI) in patients referring to Tehran Modarres Hospital was investigated during 2 years. Data regarding air quality index were gathered from the Tehran meteorological organization. Air quality index during the 24 hours before STEMI was gathered as case periods and data of air pollutions on one, two and three weeks before the event was collected as control periods. Data analysis was performed using SPSS statistical software. Logistic regression was used to compare air pollutants exposure during case and control periods.
The current study included 208 patients admitted with a diagnosis of STEMI. A positive correlation was detected between average AQI in 24 hours before infarction and STEMI (OR: 1.006; CI: 95%; 1.011-1.001). In other words, for each 10-fold increase in AQI, the risk of STEMI increases by 0.6% for each person. Furthermore, STEMI was increased more significantly in male, people over the age of 60, and diabetic patients according to increase of AQI.
The results of this study showed that air pollution increases the risk of acute myocardial infarction. Thus, more restrictive legislations should be applied to define a safe level of air pollutant production

The use of vagal nerve stimulation is identified as a proper treatment option in patients with stable supraventricular tachycardia (SVT). This study aimed to assess the success of Valsalva maneuver via a handmade device in reversion of SVT.

In this quasi experimental study, using a handmade device, vagus nerve stimulation was performed for SVT patients presenting to emergency department or cardiac intervention unit and the success rate and its related factors were assessed.

100 patients with the mean age of 53.05 § 13.70 years were studied (67% female). 12 (12%) cases were unable to do the maneuver. Out of the 88 (88.0%) patients who could perform the maneuver, 75 (85.2%) cases were unsuccessful. Dysrhythmia was controlled in 6 (6.8%) cases on the first attempt and in 7 (8.0%) cases on the second one (14.8% total success rate). 12 of the 13 cases (92.3%) of successful maneuver had history of SVT (p = 0.031). There was not any significant association between success rate and sex (p = 0.084), age (p = 0.744), or other medical histories (p ¸ 0.05).

Based on the results of the present study, the success rate of Valsalva maneuver with the mentioned handmade device was calculated to be 14.8%. The only independent related factor of successful reversion was SVT history.

T-wave oversensing is a relatively prevalent cause of intracardiac signals oversensing in patients with Implantable Cardioverter Defibrillator (ICD). Some of these oversensings are typically corrected with device reprogramming. If reprogramming fails to resolve the issue, invasive options such as repositioning the implanted lead may be necessary. We present a patient with dilated cardiomyopathy and intermittent T wave oversensing by a cardiac resynchronization therapy (CRT) that was managed by altering V-V timing.

A 22-year-old pregnant woman referred with syncope due to pacemaker malfunction. During the second trimester of pregnancy, the right ventricular (RV) lead pacing threshold increased and led to early generator depletion. We believe that this might happen due to lead micro-dislodgement or less probably effect of hormonal changes during pregnancy on electrode-myocardium interface.

Venous obstruction is relatively frequentfollowing permanent pacemaker orimplantable cardioverter-defibrillator(ICD)implantation. However, most of them are asymptomatic. Although the exact risk factor for this complication isnot known, number of leads, heart failure and infection may prone the patient to this complication. The goal standard for detection of vein stenosis is venography; however, ultrasound sonography has an acceptable accuracy. Anticoagulant therapy may be considered for symptomatic patients. For device upgrading, non-functional leads removal, venoplasty and rarely surgical treatment may be indicated.

Different types of supraventricular tachycardia have been reported in patients with history of surgical repair of Tetralogy of Fallot. This report presents appearance of focal atrial tachycardia during radiofrequency ablation of the cavotricuspid isthmus

There have been incompatible evidences about the prognostic value of HbA1c on the adverse outcomes in acute coronary syndrome. Also, these data are so limited in nondiabetic patients with unstable angina.
In this cross-sectional study, HbA1c level of 231 nondiabetic patients admitted with unstable angina, was measured using high performance liquid affinity chromatography (HPLC) at admission. Then transthoracic echocardiography (TTE) was performed for evaluation of ejection fraction (EF) using Simpson method.
Our data revealed that HbA1c was significantly higher in patients with EF≤ 50% in comparison with EF>50% group (P value=0.01).
HbA1c may be a helpful prognostic marker in nondiabetic patients admitted in emergency department with diagnosis of unstable angina.

Prognosis of the patients with beta blocker or calcium channel blocker induced AV block is not well known to date.
All patients with symptomatic second-degree or third-degree atrioventricular block (AV) referred to our institution during one year were recuited prospectively and classified in two groups based on drug consumption (beta blocker/calcium channel blocker versus none). They were followed for six months and then collected data was analyzed.
The study included 49 patients, 28 patients (age 60.1 ± 20, 19 male) did not use any beta blocker or calcium channel blocker (No- DU group) and other 21 patients (age 73.5 ± 10.4, 7 male) receivd beta blocker, calcium channel blocker or both at the time of AV block (DU group). No-DU group was significantly younger than DU group. The most common atrial rhythm in both groups was sinus. There was no significant difference in QRS wideness or ventricular rate. AV block regressed in 43% of the DU group after discontinuation of drug for five half-life, but, Mobitz type 2 or complete AV block occurred again during six months in 50% of them without consumption of the culprit drug.
More than two third of the patients who developed AV block on beta blocker and/or calcium channel blocker needed permanent pacemaker in six months of follow- up, so we concluded that the development of AV block was not as benign as it seems in these patients.

Differentiating ischemic from nonischemic cardiomyopathy is important both prognostically and therapeutically, although it may be difficult clinically.. We aimed to determine the diagnostic power of Cardiogoniometry (CGM) in the differentiation of the ischemic from the nonischemic etiology of left bundle branch block (LBBB)..Patients and We studied 37 patients with LBBB on the electrocardiogram (ECG) and left ventricular ejection fraction (LVEF) < 30%. All of them underwent coronary angiography, and 33 patients were included. Eighteen patients were categorized as the ischemic cardiomyopathy group, and 15 patients with normal coronary angiography were assigned to the nonischemic cardiomyopathy group. Then, CGM parameters were studied and compared between the two groups.. Both ischemic and nonischemic cardiomyopathy groups were similar in age, LVEF, weight, height, and body mass index. Interestingly, there were no significant differences in the average value of the 40 CGM parameters that were analyzed in this study between the two study groups.. When LBBB is the underlying rhythm, CGM cannot differentiate ischemic from nonischemic patients with good accuracy. Large studies, however, are needed to confirm our results..

Brugada Syndrome is a cardiac ion channel disorder that affects the sodium current. This syndrome is characterized by cove-shaped ST elevation in ECG leads V1 to V3 in the absence of structural heart disease.. A 36-year-old man diagnosed with Brugada Syndrome was reffered to our center with frequent implantable cardioverter-defibrillator (ICD) discharges. ICD interrogation showed several appropriate ICD intervention for tachycardia detected in the ventricular fibrillation zone. Unfortunately, quinidine was not available in our country at the time of admission; therefore, we decided to ablate suspicious arrhythmogenic substrates. Programmed ventricular stimulation from right ventricle (RV) reproducibly induced a sustained ventricular tachycardia with left bundle branch block morphology and inferior axis. RV outflow tract (RVOT) endocardially mapped and earliest activation signal (90 milliseconds) achieved at posterior aspect of the RVOT septum. RF energy application at that site terminated the tachycardia and no inducible tachycardia was detected. During two-year follow-up, he had no episodes of ICD therapy and remained symptom-free with any antiarrhythmic drug.. This case clearly indicated that catheter ablation might be considered as a viable option in every patient with Brugada syndrome and frequent ICD discharge. During the electrophysiology study, intravenous procainamide may also be used to reveal future arrhythmogenic focus in this group of patients..

Cigarette smoking increases the risk of ventricular fibrillation and sudden cardiac death (SCD). QT dispersion (QTD) is an important predictor of cardiac arrhythmia. The aim of this study was to assess the acute effect of smoking a single standard cigarette containing 1.7 mg nicotine on QT interval and QTD in healthy smokers and nonsmokers. The study sample population consisted of 40 healthy male hospital staff, including 20 smokers and 20 nonsmokers. They were asked to refrain from smoking at least 6 h before attending the study. A 12-lead surface electrocardiogram (ECG), recorded at paper speed of 50 mm/s, was obtained from all participants before and 10 min after smoking of a single complete cigarette. QT interval, corrected QT interval, QTD, and corrected QT dispersion (QTcD) were measured before and after smoking. Smokers and nonsmokers did not have any significant differences in heart rate (HR) (before smoking = 67.35 ± 5.14 vs. 67.70 ± 5.07, after smoking = 76.70 ± 6.50 vs. 76.85 ± 6.50, respectively), QTD (before smoking = 37.75 ± 7.16 vs. 39.15 ± 6.55, after smoking = 44.75 ± 11.97 vs. 45.50 ± 9.58, respectively), and QTcD (before smoking = 39.85 ± 7.40 vs. 41.55 ± 6.57, after smoking = 50.70 ± 14.31 vs. 51.50 ± 11.71, respectively). However, after smoking a single cigarette, HR, mean QTD, and QTcD significantly increased (all had P value <0.001) in comparison to the measures before smoking. Smoking of a single complete cigarette in both smokers and nonsmokers results in significant QTD increase, which can cause arrhythmia and SCD.