Electrocardiographic left ventricular hypertrophy is not associated with increased in-hospital adverse events in patients experiencing first non-ST segment elevation myocardial infarction: A single center study

Background: There is conflicting data about prognostic implication of electrocardiographic (ECG) left ventricular hypertrophy (LVH) in patients with first non- ST-segment elevation myocardial infarction (NSTEMI). We aimed to examine the association of left ventricular hypertrophy (LVH) on admission electrocardiogram with adverse outcomes in patients with NSTEMI. Methods: In the present study, 460 patients (77.5 males with mean age of 65.44±13.15 years) with first NSTEMI were evaluated. ECG left ventricular hypertrophy (LVH) was diagnosed based on Sokolow-Lyon voltage criteria. Baseline laboratory and clinical results, angiographic data, as well as in- hospital adverse events were compared between the patients with and without LVH. Results: Electrocardiographic LVH was observed in 74 (16.1) patients. Patients with LVH had higher admission systolic blood pressure (132.91±21.08 vs 125.80±21.78; P=0.01) and higher peak troponin (6.42±1.03 vs 4.41±0.28; P=0.004), but less likely to undergo coronary angiography (54.1 vs 66.8; P=0.03) .Patients with electrocardiographic LVH had similar in-hospital mortality (5.4 vs 3.6, P=0.5) and heart failure/ pulmonary edema (2.7 vs 2.07, P=0.6) compared to patients without LVH. Conclusion: The present study showed that among the patients with first NSTEMI, electrocardiographic LVH was not associated with increased in-hospital adverse events

Comparison of the Efficacy of Atorvastatin and Rosuvastatin in Preventing Atrial Fibrillation after Coronary Artery Bypass Grafting: A Double-blind Randomized Comparative Trial

Background: Atrial fibrillation (AF) is a supraventricular tachyarrhythmia characterized by disorganized atrial activity and subsequent mechanical atrial failure. Postoperative AF is a frequent complication of coronary artery bypass grafting (CABG). Although there is evidence of decreased AF after CABG with statin usage, information is scarce regarding a direct comparison between atorvastatin and rosuvastatin. The present study was conducted to compare the efficacy of rosuvastatin and atorvastatin in preventing post-CABG AF. Methods: The present double-blind randomized comparative clinical trial selected CABG candidates with stable ischemic heart disease or acute coronary syndromes. Atorvastatin (40 mg per day) or rosuvastatin (20 mg per day) was prescribed 1 week before surgery, and the outcomes were compared. Results: Two-hundred patients, 100 cases in each group, completed the study. Twenty-five patients in each group were female, and the mean age was 59.30±8.42 years in the rosuvastatin group and 60.13±9.40 years in the atorvastatin group (P=0.513). The frequency of AF was 31% in the atorvastatin group and 27% in the rosuvastatin group (P=0.534). No significant differences existed between the groups concerning the length of hospital and ICU stay (P=0.333 and P=0.161) and in-hospital and 3-month mortality (P=0.315 and P=0.648). A subgroup analysis of only patients with stable ischemic heart disease could not detect a significant difference between the study groups in any of the investigated outcomes. Our logistic regression analysis showed an association only between age and the incidence of AF after CABG (OR, 1.12; 95% CI, 1.05 to 1.20; P<0.01). Conclusion: Rosuvastatin and atorvastatin are similar concerning the prevention of post-CABG AF, but there is a need for future well-designed multicenter studies on this topic.

Mitral Regurgitation after Percutaneous Balloon Mitral Valvotomy in Patients with Rheumatic Mitral Stenosis: A Single-Center Study

Background: Percutaneous balloon mitral valvotomy (BMV) is the gold standard treatment for rheumatic mitral stenosis (MS) in that it causes significant changes in mitral valve area (MVA) and improves leaflet mobility. Development of or increase in mitral regurgitation (MR) is common after BMV. This study evaluated MR severity and its changes after BMV in Iranian patients. Methods: We prospectively evaluated consecutive patients with severe rheumatic MS undergoing BMV using the Inoue balloon technique between February 2010 and January 2013 in Madani Heart Center, Tabriz, Iran. New York Heart Association (NYHA) functional class and echocardiographic and catheterization data, including MVA, mitral valve mean and peak gradient (MVPG and MVMG), left atrial (LA) pressure, pulmonary artery systolic pressure (PAPs), and MR severity before and after BMV, were evaluated. Results: Totally, 105 patients (80% female) at a mean age of 45.81 ± 13.37 years were enrolled. NYHA class was significantly improved after BMV: 55.2% of the patients were in NYHA functional class III before BMV compared to 36.2% after the procedure (p value < 0.001). MVA significantly increased (mean area = 0.64 ± 0.29 cm2 before BMV vs. 1.90 ± 0.22 cm2 after BMV; p value < 0.001) and PAPs, LA pressure, MVPG, and MVMG significantly decreased. MR severity did not change in 82 (78.1%) patients, but it increased in 18 (17.1%) and decreased in 5 (4.8%) patients. Patients with increased MR had a significantly higher calcification score (2.03 ± 0.53 vs.1.50 ± 0.51; p value < 0.001) and lower MVA before BMV (0.81± 0.23 vs.0.94 ± 0.18; p value = 0.010). There were no major complications. Conclusion: In our study, BMV had excellent immediate hemodynamic and clinical results inasmuch as MR severity increased only in some patients and, interestingly, decreased in a few. Our results, underscore BMV efficacy in severe MS. The echocardiographic calcification score was useful for identifying patients likely to have MR development or MR increase after BMV

Usefulness of Dipyridamole Myocardial Perfusion SPECT in Patients with Left Bundle Branch Block

Background: Diagnosis of coronary artery disease (CAD) in patients with left bundle branch block (LBBB) is considered as a challenge in cardiology due to the low accuracy of noninvasive methods such as basal and stress electrocardiography (ECG). This diagnostic challenge can be reduced but not eliminated using dipyridamole as a stress method instead of exercise. The aim of this study was to assess the diagnostic value of dipyridamole stress Tc-99m Sestamibi single photon emission computed tomography (SPECT) myocardial perfusion imaging in patients with complete LBBB. Methods: We studied 40 patients with permanent and complete LBBB using Tc-99m Sestamibi SPECT and dipyridamole stress to evaluate CAD. Perfusion defect was considered fixed when there was no difference between rest and stress score, while reversible defect was defined as a segment with higher score on stress images. All patients underwent coronary angiography. Results: Eleven patients (27.5%) had normal myocardial perfusion SPECT and 29 patients (72.5%) had reversible perfusion defects. Angiography was positive in 30 patients, while 10 cases showed normal angiography. The sensitivity, specificity, positive predict value and negative predict value of our study for detecting >50% coronary stenosis was 86.6%, 70%, 89% and 64% respectively. Conclusion: We found 33 (82.5%) patients with concordant angiography and myocardial perfusion SPECT results (p=0.002). Angiography was positive in 90% of patients with reversible perfusion defects on myocardial perfusion SPECT. In summary, Tc-99m Sestamibi SPECT in patients with LBBB showed high accuracy (82.5%) in detecting >50% coronary stenosis

The Twelve-Month Outcome of Biolimus Eluting Stent with Biodegradable Polymer Compared With an Everolimus Eluting Stent with Durable Polymer

Introduction: Drug-eluting stents (DES) have significantly decreased the need for repeat coronary revascularization but concerns remain regarding the safety of first and second generation DES. We compared the safety and efficacy of a biolimus-eluting stent (with biodegradable polymer) with an everolimus-eluting stent (with durable polymer) one. Methods: We performed a randomized trial to compare the two types of stents. Two hundred patients undergoing PCI for de novo lesions were randomly assigned 1:1 to treatment with either biolimus-eluting (BioMatrix) or everolimus -eluting (Xience V) stent. The primary endpoint was a composite of cardiac death, myocardial infarction, and clinically driven target vessel revascularization within 12 months. Results: Demographics, clinical, and lesion characteristic were comparable between two groups. The 30-day major adverse cardiac event (MACE) rate was 2% in BioMatrix group versus 0% in Xience group (p > 0.05). After 12 months, the rates of cardiac death (0% in both groups), MI (2% versus 0%, p=0.49) and clinically –driven target vessel revascularization (0% in both groups) were similar for BioMatrix and Xience. No stent thrombosis was reported at 1, 6, 9 or 12 months after intervention in either group. Conclusion: BES (Biolimus-eluting stent) with biodegradable polymer and EES (Everolimus-eluting stent) with durable polymer appear similar with respect to MACE and stent thrombosis in this patient population. Many studies with longer follow up are needed to define better the role of BES with biodegradable polymer in treatment of coronary artery lesions

Electrocardiographic P-wave Indices as a Useful Tool to Predict Successful Percutaneous Balloon Mitral Valvotomy in Patients with Mitral Stenosis

Introduction: Patients with hemodynamically significant mitral stenosis (MS) have prolonged P-wave duration and increased P-wave dispersion (PWD) that decreases after successful percutaneous balloon mitral valvotomy (PBMV). The purpose of this study was to investigate if the changes in these indices may predict a successful procedure. Methods: Fifty two patients with MS in sinus rhythm underwent PBMV (90.4% female; mean age 38±10 years). Mitral valve area (MVA), valve score, mean diastolic mitral gradient (mMVG), mitral regurgitation severity, and systolic pulmonary artery pressure (sPAP) were evaluated by echocardiography before PBMV and repeated after one month. P-wave duration (Pmax / Pmin) and PWD were measured before and immediately after PBMV, at discharge, and at the end of the first month after discharge. Results: Among all procedures 38 (73.1%) were defined as successful. Mean age, valve score, mMVG, and MVA before PBMV were similar for both groups. MVA was significantly greater in the successful PBMV group (1.65±0.27 vs. 1.41±0.22; p= 0.003). sPAP was reduced after PBMV in all patients and there were no significant differences in the mean sPAP before and after PBMV in both successful and unsuccessful groups. Pmax and PWD were significantly decreased immediately after the procedure (p= 0.035), the next day (p= 0.005) and at one month (p= 0.002) only in patients with successful PBMV. Pmin did not change significantly in either group. Conclusion: Only successful PBMV was associated with a decrease in Pmax and PWD. These simple electrocardiographic indices may predict the success of the procedure immediately after PBMV

Evaluation of Patients’ Exposure during Angiography and Angioplasty Procedures in the Angiography Department of Shahid Madani Hospital in Tabriz

Introduction: Coronary angiography and angioplasty procedures lead to significant radiation exposure of patients. In the current study, the average radiation dose to patients during angiography in the Angiography Department of Shahid-Madani Hospital was determined. Materials and Methods: An image intensifier based angiography unit (Philips BH 3000) was used for angiography procedures. The accuracy of the internal dosimeter was verified. Dose-area products (DAP) of patients (236 cases) during fluoroscopy and cine acquisition were recorded. Analyzing the data, the average radiation doses to patients for angiography and angioplasty and also for fluoroscopy and cine acquisition were determined. Additionally, the average fluoroscopy time for all patients was estimated. Results: The average DAPs of 23.7 and 91.5 Gycm2 were estimated for angiography and angioplasty respectively. Patient doses including fluoroscopy, cine acquisition and the total dose for angiography were 2, 7.7 and 3.8 times lower than angioplasty procedures respectively. Average fluoroscopy time was 1.9 times lower for angiography compared to angioplasty. Discussion and Conclusion: Fluoroscopy time and patient dose during fluoroscopy were in good agreement with other studies. However, the dose to patients during angioplasty was higher compared to other reports. To reduce patient dose in angioplasty procedures, the use of the lowest available frame rate, smallest field size and retraining of operators and technologists are recommended

Poor outcome following percutaneous balloon mitral valvotomy in patients with atrial fibrillation

Introduction: Atrial fibrillation (AF) is the most common arrhythmia in patients with mitral stenosis (MS) and it may increase complications and decreases success rates of percutaneous balloon mitral valvotomy (PBMV). This study aimed to investigate the short and long term results of PBMV in patients with AF compared to sinus rhythm (SR). Methods: In this cross sectional study, 1000 patients with MS who had undergone PBMV between 1999 and 2013 were enrolled including 585 and 415 patients with AF and SR respectively. Patients were followed for a mean of 7.27 ± 3.16 years. Clinical, echocardiographic and hemodynamic data were collected. Procedure success, in-hospital and long-term outcome were evaluated. Results: Patients with AF were older and had greater symptoms, mitral regurgitation, mitral echocardiographic score, and mitral pressure gradient before PBMV. PBMV success rate were significantly lower in AF group (P < 0.001). In-hospital complications, including severe mitral regurgitation, emergency mitral valve surgery, peripheral embolism and long-term complications, including mortality, re-valvotomy, mitral replacement surgery and peripheral embolism/stroke were significantly higher in patients with AF. Conclusion: AF leads to worse in-hospital and long-term outcome and lower PBMV success rate. Repeated assessment and early decision to PBMV in patients with MS to reduce AF and AF related complication seems necessary

Changes in Serum NT-Pro BNP and Left Atrial BNP Levels after Percutaneous Transvenous Mitral Commissurotomy in Sinus Rhythm Versus Atrial Firilation

Introduction: Natriuretic peptides are secreted from the heart in response to increased wall stress. Their levels are expected to be increased in patients with mitral stenosis (MS) due tohigh left atrium (LA) pressure and pulmonary artery pressure (PAP). Percutaneous transvenousmitral commissurotomy (PTMC) if successful is pursued by a rapid decrease in LA pressure andsubsequent decrease in pulmonary artery pressure. The concurrent changes in natriuretic peptidelevels could be affected with heart rhythm.Methods: Forty five patients with severe rheumatic MS undergoing PTMC were enrolled. Weevaluated the serum NT-Pro BNP levels before and 24 hours after PTMC. BNP levels were alsomeasured from the blood samples obtained from LA before and 20 minutes after the procedure.Changes in biomarkers were assessed based on heart rhythm and success of the procedure.Results: While serum NT-Pro BNP levels showed significant decrease 24 hours after theprocedure (P= 0.04), BNP levels taken 20 minutes after PTMC from LA were similar to theirbaseline concentrations (P= 0.26). NT-Pro BNP levels decreased 51.7±182.86 pg/ml for SR and123.4±520 pg/ml for AF (P= 0.68).Conclusion: Immediate changes in BNP levels did not predict the success of procedure probablydue to the additional balloon inflation attempts in LA in several patients and half-life of BNP. BNPlevels obtained later may be of more value considering the half-life of this marker. Heart rhythmwas not found to influence the changes in biomarker levels. BNP and NT-pro BNP changes werenot found to predict success of the procedure