The correlation between the CT angiographic pulmonary artery obstructive index and clinical data in patients with acute pulmonary thromboembolism

PURPOSE

The potentially fatal consequences of pulmonary embolism emphasize the need for more effective diagnostic methods. The Qanadli obstruction index has been described as a convenient tool for risk stratification to determine and quantify the degree of obstruction. This study aimed to assess the correlations between the Qanadli index with clinical and paraclinical findings (D-dimer, troponin, and echocardiographic findings) in patients with pulmonary embolism.

MATERIALS AND METHODS

A total of 102 patients with pulmonary embolism underwent echocardiography and CT pulmonary angiography at a single tertiary referral center between 2019 and 2020. The clinical and paraclinical findings, pulmonary arterial obstruction index, atrial measurements, right and left ventricle size and function, tricuspid annular plane systolic excursion, pulmonary artery pressure, and pulmonary hypertension (PH) were analyzed. Vital signs were recorded and assessed. The Qanadli index score was measured, and graded risk stratification was measured based on the quantified index score.

RESULTS

The total mean Qanadli index was 28.75 ± 23.75, and there was no significant relationship between the Qanadli index and gender. Patients' most common clinical findings were exertional dyspnea (84.3%; n = 86) and chest pain (71.7%; n = 73). There were significant correlations between the Qanadli index and pulse rate (PR), troponin, D-dimer levels, and PH. Four patients died during the study, including one from a cardiac condition and three with non-cardiac conditions.

CONCLUSIONS

It is possible to determine the severity, prognosis, and appropriate treatment by the Qanadli index based on strong correlations with PR, troponin, D-dimer levels, and PH.

Hydatid cyst of papillary muscle concomitant with brain involvement

BACKGROUND

Cardiac hydatidosis is a rare disease and the subepicardial region of the left ventricular is commonly affected. However, papillary muscle concomitant with brain involvement has not been previously reported.

CASE

We report a 44 years old man who complained of headache along with no cardiac symptoms. The patient was diagnosed with cerebral hydatid cyst. Through preoperative cardiac consultant, transthoracic echocardiography revealed cardiac hydatid cyst confined to the anterolateral papillary muscle. Medical treatment was started promptly and successful surgical excision of all cysts was performed. The patient had an uneventful recovery and follow up at 3 months.

CONCLUSION

Early diagnosis of cardiac HC by echocardiography is recommended in all patients with hydatid disease, regardless of HC location.

Evaluating Post-discharge Thromboembolic Events in Patients With COVID-19

Background: COVID-19 is associated with a high rate of thromboembolic events in hospitalized patients, but it is unclear whether this risk remains high after discharge. This study aimed to evaluate the association of underlying factors with post-discharge thrombolytic events in COVID-19 patients and the association of thrombolytic events with subsequent mortality and ischemic heart disease. Methods: In this study, eligible patients with COVID-19 who were admitted to the respiratory ward of Loghman Hakim Hospital, Tehran, Iran, followed up for about 3 months after discharge to record any thromboembolic events. Patients who reported postdischarge thromboembolic events were confirmed based on their diagnostic tests. The Chi-square test was used to evaluate the association between thromboembolic events and qualitative parameters, and an independent t-test was used to evaluate their association with quantitative parameters. Logistic regression analysis was performed to assess the association between independent variables and the composite outcome. Results: Thromboembolic events were diagnosed in 35 patients (5.04%), including Myocardial Infarction (MI) in 17 patients (2.44%), venous thromboembolism in 10 patients (1.44%), and ischemic stroke in 8 patients (1.15%). None of the 26 patients who received thromboprophylaxis had thromboembolic events. During follow-up, 22 patients (3.17%) died, of whom, 10 patients (43.47%) had thromboembolic events. Thromboembolic events were not associated with sedentary life and oxygen (O2) dependency after discharge (P value of 0.40 and 0.098, respectively). Regression analyses showed that thromboembolic events were significantly associated with ischemic heart disease and mortality (P=0.007 and P<0.001, respectively). Conclusion: Our findings support a high rate of post-hospitalization thromboembolic events in COVID-19 patients; however, it needs more large-scale trials.

Association between Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers and Mortality in Patients with Hypertension Hospitalized with COVID-19

Background: Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are common hypertension medications. We aimed to investigate the association between treatment with ACEIs/ARBs and disease severity and mortality in patients with hypertension hospitalized for coronavirus disease 2019 (COVID-19). Methods: Information from the medical records of 180 hospitalized patients diagnosed with COVID-19 infection admitted in 2020 to Loghman Hakim Hospital, Tehran, Iran, was collected. Clinical histories, drug therapies, radiological findings, hospital courses, and outcomes were analyzed in all the patients. The demographic and clinical characteristics of the patients were also analyzed, and the percentage of patients with hypertension taking ACEIs/ARBs was compared between survivors and nonsurvivors. Results: The study population consisted of 180 patients at mean±SD age of 67.76±18.72 years. Hypertension was reported in 72 patients (40.0%). Patients with hypertension were older than those without it (mean±SD age =72.35±12.09 y). Among those with hypertension, death occurred in 33 patients (45.8%), of whom 60.6% were men. Fifty-three patients (73.6%) with hypertension were on ACEIs/ARBs. The ACEIs/ARBs group had a significantly lower mortality rate than the non-ACEIs/ARBs group (37.7% vs 68.4%; OR: 0.192; 95% CI: 0.05-0.68; P=0.011). Conclusion: This single-center study found no harmful effects associated with ACEIs/ARBs treatment. Patients on ACEIs/ARBs had a lower rate of mortality and disease severity than the non-ACEIs/ARBs group. Our study supports the current guideline to continue ACEIs/ARBs in patients with hypertension.

Effect of COVID-19 medications on corrected QT interval and induction of torsade de pointes: Results of a multicenter national survey

BACKGROUND

There are some data showing that repurposed drugs used for the Coronavirus disease-19 (COVID-19) have potential to increase the risk of QTc prolongation and torsade de pointes (TdP), and these arrhythmic side effects have not been adequately addressed in COVID-19 patients treated with these repurposed medications.

METHODS

This is the prospective study of 2403 patients hospitalised at 13 hospitals within the COVID-19 epicentres of the Iran. These patients were treated with chloroquine, hydroxychloroquine, lopinavir/ritonavir, atazanavir/ritonavir, oseltamivir, favipiravir and remdesivir alone or in combination with azithromycin. The primary outcome of the study was incidence of critical QTc prolongation, and secondary outcomes were incidences of TdP and death.

RESULTS

Of the 2403 patients, 2365 met inclusion criteria. The primary outcome of QTc ≥ 500 ms and ∆QTc ≥ 60 ms was observed in 11.2% and 17.6% of the patients, respectively. The secondary outcomes of TdP and death were reported in 0.38% and 9.8% of the patients, respectively. The risk of critical QT prolongation increased in the presence of female gender, history of heart failure, treatment with hydroxychloroquine, azithromycin combination therapy, simultaneous furosemide or beta-blocker therapy and acute renal or hepatic dysfunction. However, the risk of TdP was predicted by treatment with lopinavir-ritonavir, simultaneous amiodarone or furosemide administration and hypokalaemia during treatment.

CONCLUSION

This cohort showed significant QTc prolongation with all COVID-19 medications studied, however, life-threatening arrhythmia of TdP occurred rarely. Among the repurposed drugs studied, hydroxychloroquine or lopinavir-ritonavir alone or in combination with azithromycin clearly demonstrated to increase the risk of critical QT prolongation and/or TdP.

Association of Warfarin Therapy with APOE and VKORC1 Genes Polymorphism in Iranian Population

Warfarin is a vitamin K antagonist that genetic and non-genetic factors affected on its dose requirement in the patients with cardio vascular disease. The aim of this study was whether the APOE and VKORC1 polymorphisms influence on warfarin dose requirements in the part of Iranian patients. Blood samples were collected from 86 warfarin-treated patients. After extraction of genomic DNA, the VKORC1 (rs9923231) and the APOE (rs429358 and rs7412) polymorphisms were genotyped by PCR-RFLP technique. We found that the Iranian patients carrying genotypes GA or AA of VKORC1 polymorphism tended to receive lower dose of warfarin (p = 0.018). Furthermore, the E3/E3 genotype was observed with the frequency more than 60% in the patients with low dose of warfarin. The BMI and weight also showed a positive correlation with warfarin dose. However, it was not statistically significant (p > 0.05). The results of this study may be useful in defining of warfarin dose algorithms for Iranian patients.

A Novel Risk Score in Predicting Failure or Success for Antegrade Approach to Percutaneous Coronary Intervention of Chronic Total Occlusion: Antegrade CTO Score

Total occlusion of a coronary artery for more than 3 months is defined as chronic total occlusion (CTO). The goal of this study was to develop a risk score in predicting failure or success during attempted percutaneous coronary intervention (PCI) of CTO lesions using antegrade approach. This study was based on retrospective analyses of clinical and angiographic characteristics of CTO lesions that were assessed between February 2012 and February 2014. Success rate was defined as passing through occlusion with successful stent deployment using an antegrade approach. A total of 188 patients were studied. Mean ± SD age was 59 ± 9 years. Failure rate was 33%. In a stepwise multivariate regression analysis, bridging collaterals (OR = 6.7, CI = 1.97-23.17, score = 2), absence of stump (OR = 5.8, CI = 1.95-17.9, score = 2), presence of calcification (OR = 3.21, CI = 1.46-7.07, score = 1), presence of bending (OR = 2.8, CI = 1.28-6.10, score = 1), presence of near side branch (OR = 2.7, CI = 1.08-6.57, score = 1), and absence of retrograde filling (OR = 2.5, CI = 1.03-6.17, score = 1) were independent predictors of PCI failure. A score of 7 or more was associated with 100% failure rate whereas a score of 2 or less was associated with over 80% success rate. Most factors associated with failure of CTO-PCI are related to lesion characteristics. A new risk score (range 0-8) is developed to predict CTO-PCI success or failure rate during antegrade approach as a guide before attempting PCI of CTO lesions.

Thrombolytic Therapy for Right-Sided Mechanical Pulmonic and Tricuspid Valves: The Largest Survival Analysis to Date

Data regarding thrombolytic treatment of right-sided mechanical valve thrombosis are almost nonexistent, and all current guidelines arise from very small case series. We retrospectively studied the in-hospital and long-term outcome data of a larger series of patients who had received, from September 2005 through June 2012, thrombolytic therapy for right-sided mechanical pulmonary valve or tricuspid valve thrombosis. We identified 16 patients aged 8-67 years who had undergone thrombolytic therapy for definite thrombotic mechanical valve obstruction in the tricuspid or pulmonary valve position (8 in each position). All study patients except one had subtherapeutic international normalized ratios. The 8 patients with pulmonary mechanical valve thrombosis had a 100% response rate to thrombolytic therapy, and their in-hospital survival rate was also 100%. The 8 patients with tricuspid mechanical valve thrombosis had a 75% response rate to thrombolytic therapy, with an in-hospital survival rate of 87.5%. The one-year survival rate for mechanical valve thrombosis treated with thrombolytic therapy (whether pulmonary or tricuspid) was 87.5%. On the basis of our data, we recommend that thrombolytic therapy remain the first-line therapy for right-sided mechanical valve thrombosis in adults or children-including children with complex congenital heart disease and patients with mechanical pulmonary valve thrombosis. Surgery should be reserved for patients in whom this treatment fails.

Successful Treatment of Aluminium Phosphide Poisoning by Extracorporeal Membrane Oxygenation

Aluminium phosphide (ALP) is one of the most commonly used pesticides worldwide with high mortality rates. Cellular damage and cardiorespiratory failure are the most common causes of mortality and morbidity after poisoning. It is supposed that giving enough time to the patient to survive, the most critical hours after exposure may help the cardiovascular system to recover itself and save the patient's life. During a training workshop for medical extracorporeal membrane oxygenation (ECMO), a 28-year-old ALP-poisoned male was referred to us. Fifty minutes after admission, he developed hypotension and bradycardia and was transferred to ICU. On the second venous blood gas, he had severe metabolic acidosis. After starting the patient on the routine treatment of ALP poisoning, he was a candidate for veno-arterial (VA) ECMO. After three days, lactate level decreased and his general condition improved. On day four, the patient was completely separated from the ECMO machine with acceptable echocardiography and ejection fraction of 40%. One day later, he was extubated, sent to the ward and subsequently discharged in good condition. We suggest this method of treatment for severe ALP poisoning as well as any other poisoning that causes cell toxicity and abrupt cardiovascular or respiratory failure.

Acute ST-segment elevation myocardial infarction as the first manifestation of essential thrombocytosis successfully treated with thrombectomy alone

A patient with no conventional cardiovascular risk factors presented with inferior ST-elevation myocardial infarction which was finally diagnosed as a case of essential thrombocytosis. This case demonstrated that thrombectomy alone was sufficient for the treatment of his coronary occlusion. Furthermore, this case report highlights the importance of evaluating rare causes of myocardial infarction other than atherosclerosis and that internists and cardiologists should be aware of essential thrombocytosis as a known cause of myocardial infarction, particularly in patients with no underlying cardiovascular risk factors.

Evaluation of effective factors in success rate of intervention on CTO

Chronic total occlusion (CTO) intervention is still a challenging problem. The aim of this study is to determine factors that affect PCI results.

METHOD AND RESULTS

The study was conducted on 72 patients in two centers. CTO angioplasty was done by the antegrade approach from the femoral and/or radial approach. The role of age, gender, anatomical variations such as calcification, length of the lesion, proximal bending, retrograde filling and occluded coronary artery (LAD, CCK or RCA), and wires were assessed. The success rate was 79.6%, and presence of calcification was an important factor in CTO PCI. Operator's experience, use of appropriate equipment and calcification are important factors in predicting a successful PCI.

The effects of different doses of atorvastatin on serum lipid profile, glycemic control, and liver enzymes in patients with ischemic cerebrovascular accident

BACKGROUND

Despite established effects of atorvastatin on level of serum lipid profile in patients with different underlying clinical conditions, the effects of this drug on other serum biomarkers remain uncertain. We examined the effects of atorvastatin therapy on lipid profile, glycemic control, and liver enzymes in patients with ischemic cerebrovascular accident without any history or clinical evidences of diabetes, heart failure, renal failure, or hepatic disease.

METHODS

In a randomized double-blinded controlled trial, 140 hospitalized patients with an ischemic cerebrovascular accident were included and randomly assigned to receive either atorvastatin 40 mg (n = 70) or atorvastatin 20 mg daily (n = 70) for 3 months. The levels of biomarkers were measured at the time of administrating drugs as well as at the time of completing the treatment.

RESULTS

A significant reduction was revealed in serum triglyceride, total cholesterol, low-density lipoprotein, non-high-density lipoprotein (HDL) cholesterol, and also aspartate aminotransferase levels as well as a significant increase in serum HDL level following administration of atorvastatin in both case and control groups who received the atorvastatin 40 mg/day and 20 mg/day, respectively (all P < 0.050). Although a significant increase in fasting blood sugar and hemoglobin A1c was observed in the case group received atorvastatin 40 mg/day (both P < 0.001), but this elevation was not occurred in another group treated with lower dose of the drug (both P > 0.050).

CONCLUSION

Daily administration of 20 mg and 40 mg doses of atorvastatin for 3 months provides improvement in serum lipid profiles; however, because of interfering effect of high-dose atorvastatin on glycemic control status, the use of the former dose may be preferred. This is very important in these patients because the positive effects of high-dose atorvastatin in stroke patients are not confirmed.

Thrombolytic-plus-Anticoagulant Therapy versus Anticoagulant-Alone Therapy in Submassive Pulmonary Thromboembolism (TVASPE Study): A Randomized Clinical Trial

BACKGROUND

The use of thrombolytic agents in the treatment of hemodynamically stable patients with acute submassive pulmonary embolism (PTE) remains controversial. We, therefore, conducted this study to compare the effect of thrombolytic plus anticoagulation versus anticoagulation alone on early death and adverse outcome following submassive PTE.

METHODS

We conducted a study of patients with acute pulmonary embolism and pulmonary hypertension or right ventricular dilatation/dysfunction but without arterial hypotension or shock. The patients were randomly assigned in a single-blind fashion to receive an anticoagulant [Enoxaparin (1 mg/kg twice a day)] plus a thrombolytic [Alteplase (100 mg) or Streptokinase (1500000 u/2 hours)] or an anticoagulant [Enoxaparin (1 mg/kg twice a day)] alone. The primary endpoint was in-hospital death or clinical deterioration requiring an escalation of treatment. The secondary endpoints of the study were major bleeding, pulmonary hypertension, right ventricular dilatation at the end of the first week, and exertional dyspnea at the end of the first month.

RESULTS

Of 50 patients enrolled, 25 patients were randomly assigned to receive an anticoagulant plus a thrombolytic and the other 25 patients were given an anticoagulant alone. The incidence of the primary endpoints was significantly higher in the anticoagulant-alone group than in the thrombolytic-plus-anticoagulant group (p value = 0.022). At the time of discharge, pulmonary artery pressure was significantly higher in the anticoagulant-alone group than in the thrombolytic-plus-anticoagulant group (p value = 0.018); however, reduction in the right ventricular size or normalization of the right ventricle showed non-significant differences between the two groups. There was no significant difference regarding the New York Heat Association (NYHA) functional class between the two groups at the end of the first month (p value = 0.213). No fatal bleeding or cerebral bleeding occurred in the patients receiving an anticoagulant plus a thrombolytic.

CONCLUSION

When given in conjunction with anticoagulants, thrombolytics may improve the clinical course of stable patients who have acute submassive pulmonary embolism and prevent clinical deterioration.

Evaluation of QT, QT dispersion, and T-wave peak to end time changes after primary percutaneous coronary intervention in patients presenting with acute ST-elevation myocardial infarction

BACKGROUND

Acute ST-elevation myocardial infarction (STEMI) is associated with significant arrhythmia and cardiac arrest. QT prolongation can occur in the setting of ischemia or acute STEMI as a risk factor for arrhythmia. The goal of this study was to investigate corrected QT interval (QTc), QT dispersion (QTd), and T-wave peak to end (TPE) times in this patient population and evaluate the effect of primary percutaneous coronary intervention (PCI) in STEMI patients on these indices.

METHODS

This study was a clinical trial, whereby eligible patients presenting with acute STEMI who were appropriate candidates for primary PCI were enrolled. QTc, QTd, and TPE indices were calculated before and after the procedure.

RESULTS

Eighty patients (60 male, 20 female) with a mean age of 58.8 years were evaluated. We found significant reduction in QTd after PCI (mean, 5.8 ms before PCI vs 3.6 ms after PCI; P<.001) and significant reduction in TPE after PCI (mean, 9.7 ms before PCI vs 7 ms after PCI; P<.001). QTc did not show significant changes before or after PCI (44.9 vs 43.7; P=.057).

CONCLUSION

Our study showed that primary PCI was effective in reducing the degree of arrhythmogenic indices such as QTd and TPE. Our findings suggest that ischemia-induced QTd and TPE are important arrhythmogenic parameters responding to successful primary PCI and may be used as markers for successful repercussion.

Report of methamphetamine use and cardiomyopathy in three patients

Background

Methamphetamine (meth) is a stimulant used illegally around the world, including in Iran. Cardiomyopathy and cardiac failure may occur following chronic meth use and may cause the patients referred to the emergency department.

Case reports

A 28-year old man and two women, ages 29 and 31-year-old, with a history of meth use, were admitted to the emergency department with severe dyspnea at rest. Each had sinus tachycardia with tachypnea and an echocardiogram that showed severe systolic dysfunction consistent with heart failure. Additional evaluation in the hospital revealed cardiomyopathy with no other etiology other than the meth use.

Conclusion

There are several reports that show an increase in frequency of meth use, suggesting that cardiomyopathy and acute heart failure may be a new medical concern.

Percutaneous treatment of spontaneous left main coronary artery dissection extending to the left anterior descending and circumflex arteries possibly triggered by thrombolytic therapy

Spontaneous coronary artery dissection is a rare cause of myocardial infarction and the role of thrombolytic therapy in this setting is not known. A case of acute ST elevation myocardial infarction is presented, with initial positive response to thrombolytic therapy and subsequent marked worsening of ST elevation due to extensive dissection, possibly triggered by thrombolytic therapy, which was successfully treated with percutaneous coronary intervention.

Isolated dissection of superior mesenteric artery

Isolated dissection of the superior mesenteric artery is a rare occurrence with a hitherto unknown exact etiology. Patients may present with abdominal symptoms or hemodynamic instability.We herein present a case of spontaneous isolated superior mesenteric artery dissection in a 48-year-old man, who was admitted with epigastric pain. Due to an undiagnosed paced rhythm on the electrocardiogram, he was given fibrinolysis treatment for acute myocardial infarction. On further evaluation, angiography revealed that the cause of pain was the dissection of the superior mesenteric artery. The patient's symptoms were diminished with conservative management, obviating the need for the angioplasty of the superior mesenteric artery.

Asymptomatic pediatric pulmonic valve myxoma involving the right ventricular outflow tract: a case report and review of the literature

Asymptomatic pediatric pulmonic valve myxoma involving the right ventricular out flow tract (RVOT) is very rare. The case is presented of 13-year-old asymptomatic boy who was referred to the cardiology clinic for evaluation of murmur, and was found to have a large mobile mass (3 x 2 cm) in the RVOT that protruded into the pulmonary artery across the pulmonary valve during systole, and relocated in the right ventricle in diastole. The patient underwent successful surgical excision of the tumor, which had a short stalk attached to the pulmonary valve. Macroscopic examination revealed a typical myxoma without any evidence of malignancy. This case elaborates the importance of early recognition and surgical excision of these tumors in order to prevent thromboembolic complications.

Unusual presentation of a massive pulmonary embolism

A pulmonary embolus clogs the artery that provides blood supply to a part of the lung. The embolus not only prevents the exchange of oxygen and carbon dioxide but also decreases blood supply to the lung tissue itself, potentially causing the tissue to die (infarct). A 52-year-old man presented with syncope and anxiety. He had sinus tachycardia and dilated right ventricle with trabeculations. A differential diagnosis of arrhythmogenic right ventricular dysplasia and pulmonary embolism prompted CT angiography, which revealed a bilateral massive pulmonary embolism. The patient was treated successfully with thrombolytic drugs.

Isolated noncompaction of left ventricular myocardium with an unusual presentation of angina pectoris

A 45-year-old man presented to the hospital with typical chest pain compatible with myocardial infarction. An electrocardiogram showed left bundle branch block. The patient underwent urgent coronary angiography, which revealed no significant coronary artery disease. Echocardiography showed noncompaction of the left ventricular myocardium. This unusual case of angina occurring in a patient with isolated noncompaction of the left ventricle is discussed with a review of the literature.

Coronary aneurysm and silent myocardial infarction in an adolescent secondary to undiagnosed childhood Kawasaki disease

The majority of coronary artery aneurysms in young adults and children are caused by Kawasaki disease. A case of undiagnosed childhood Kawasaki disease presenting as silent myocardial infarction during adolescence, which was successfully treated with coronary artery bypass grafting, is described. The present case is followed by a review of the literature.

Rectus hematoma- An under-recognized complication of transfemoral cardiac catheterization

We present a case of rectus hematoma occurring in the setting of transfemoral cardiac catheterization. This is a potentially deadly complication that is under-reported and under-diagnosed. The goal of this article is to present a case of rectus hematoma alongside a comprehensive review of the literature.