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Background: Acute coronary syndrome (ACS) is one of the main causes of mortality worldwide. We sought to evaluate the correlation between the severity of coronary artery disease (CAD) and conventional coronary artery risk factors in a large cohort of patients with ACS., Methods: This study included all patients admitted to the coronary care unit with a diagnosis of ACS between 2003 and 2017. The patients were divided into 2 groups: 1) unstable angina and 2) myocardial infarction. The aims of this study were to evaluate the effects of the risk factors and extension of coronary artery stenosis in patients with ACS according to the Gensini score., Results: Of a total 40 319 patients who presented with ACS, 18 862 patients (mean age =60.4±11.14 y, male: 67.2%) underwent conventional coronary angiography and met our criteria to enter the final analysis. The median of the Gensini score was 50 (25-88) in the study population. The multivariable analysis showed that age, sex, diabetes mellitus, hypertension, dyslipidemia, family history, cigarette smoking, opium consumption, and myocardial infarction increased the risk of positive Gensini scores. All the aforementioned risk factors, except cigarette smoking and opium consumption, increased the severity of stenosis in those with positive Gensini scores. The strongest relationship was seen vis-à-vis myocardial infarction, sex, and diabetes mellitus., Conclusion: Our findings suggest that age, sex, diabetes mellitus, dyslipidemia, hypertension, family history, and myocardial infarction have significant effects on the severity of CAD. The obesity paradox in relation to CAD should be taken into consideration and needs further investigation in patients with ACS., (Copyright © 2020 Tehran University of Medical Sciences.)

Background: Although invasive treatments such as primary percutaneous coronary intervention (PPCI) are the treatment of choice in ST-elevation myocardial infarction (STEMI) patients, the survival benefit of this treatment in patients with a history of coronary artery bypass graft (CABG) has yet to be fully evaluated. Methods: In this historical cohort study, 251 STEMI patients with a history of CABG between 2007 and 2017 were stratified into 3 groups of no reperfusion, thrombolytic, and PPCI based on their treatment strategy. Baseline clinical characteristics, details of the STEMI event, and the course of hospitalization were evaluated for all patients and they were followed up until May 2018 to assess all-cause mortality. Results: The mean age of the study population was 64.019.45 years, and 81.7% of them were male. The median follow-up time was 1304 (IQR 25%-75% : 571-2269) days, the short-term (1 month) mortality rate was 5.97%, and the long-term mortality rate was 15.1%. There was no significant difference between the 3 different strategies in terms of survival. In the fully adjusted multivariate analysis, cardiopulmonary resuscitation (HR: 15.06, 95% CI: 2.25-101.14, P=0.005) was significantly associated with short-term mortality, while diabetes (HR: 5.95, 95% CI: 2.03-17.44, P=0.001), opium abuse (HR: 4.85, 95% CI: 1.45-16.23, P=0.010), and cardiopulmonary resuscitation (HR: 11.73, 95% CI: 3.44-40.28, P=0.001) were significantly associated with long-term mortality. Conclusion: Our results failed to show the superiority of invasive treatment in terms of survival. Further studies regarding the advantages and disadvantages of invasive treatment in post-CABG patients are required., (Copyright © 2015 Tehran Heart Center, Tehran University of Medical Sciences.)

Background: Performing primary percutaneous coronary intervention (PPCI) in a timely fashion is a crucial part of the management of ST-elevation myocardial infarction (STEMI). We aimed to evaluate the contributing factors to and the etiologies of a prolonged door-to-device (D2D) time. Methods: In 2016, the D2D time was measured in all patients who were treated with PPCI at Tehran Hear Center. The major causes of a prolonged D2D time (>90 min) were determined. The second phase was then started in 2017 by focusing on the determined causes, and direct feedback was given to anyone having contributed to the delayed D2D time. The D2D time was compared between these 2 years. Results: The mean age of the patients was 59.54±11.82 years, and 82.2% of them were men. The median D2D time decreased from 55 minutes (IQR 25-75% : 40-82) in 2016 to 46 minutes (IQR 25-75% : 34-70) in 2017 (P<0.001). In the first year, 79.8% of the patients had a D2D time of below 90 minutes; the figure rose to 84.1% of the patients in the second year (P=0.017). The first cause of a prolonged D2D time was missed ST-elevation in the first electrocardiogram by physician or nurse (8.4% of the cases). Along with a declining rate of missed STE to 6.7%, the median D2D time in the missed patients also decreased from 205 minutes to 177 minutes (P=0.011). The rate of ambulance arrival increased from 10.2% to 20.7% of the cases, and the median D2D time also declined from 45 (IQR 25-75% : 34-55) to 34 (IQR 25-75% : 25-55) in these patients (P<0.001). Conclusion: Even in the setting of a 24/7 on-site interventionist in the hospital, the dispatch system and prehospital electrocardiograms, along with regular assessment and feedback, may improve the D2D time.

Background: Despite recent advances in interventional equipment and techniques, the angiographic no-reflow phenomenon occurs in a considerable number of patients undergoing primary percutaneous coronary intervention (PCI). We investigated the clinical, angiographic, preprocedural, and procedural characteristics associated with the no-reflow phenomenon among patients undergoing primary PCI. Methods: Between March 2008 and April 2013, 530 patients (78.5% male, mean age=58.11±12.39 y) with ST-segment-elevation myocardial-infarction who underwent primary PCI were categorized in 2 groups according to their postprocedural thrombolysis-in-myocardial infarction (TIMI) flow grades: those with a maximum score of 2 (the no-reflow or slow-flow group) and the ones with a score of 3 (the reflow group). A multivariable logistic regression model was used to find the multiple correlates of the no-reflow phenomenon after PCI. Results: There were 166 (31.3%) patients in the no-reflow group and 364 (68.7%) in the reflow group. The no-reflow patients were older and had significantly longer target lesion lengths, higher SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) scores, higher infarct-related artery SYNTAX scores, more thrombus burden, and a higher frequency of initial TIMI flow grades of 2 or lower. Our multivariable logistic regression analysis demonstrated that older age, higher numbers of Q waves, not using statin, longer target lesion lengths, higher thrombus grades, and higher infarct-related artery SYNTAX scores remained the independent correlates of increased no-reflow rates after primary PCI (area under the ROC curve=0.784, 95% CI: 0.742-0.826; P<0.001). Conclusion: Clinical, angiographic, and procedural features of patients undergoing primary PCI may be correlated with the occurrence of the no-reflow phenomenon. The thrombus grade and the infarct-related artery SYNTAX score could be among these factors.

Background: The biolimus-eluting stent (BES), with a biodegradable polymer, has not been previously compared with the everolimus-eluting stent (EES), as a second-generation drug-eluting stent (DES).We sought to compare the 1-year outcome between the PROMUS ™ stent (EES type) and the BioMatrix ™ stent (BES type). Methods: From March 2008 to September 2011, all patients treated with the PROMUS™ stent or the BioMatrix™ stent for coronary artery stenosis at Tehran Heart Center were enrolled. The primary end points were 1-year adverse events, comprising death, myocardial infarction, target vessel revascularization, and target lesion revascularization. The secondary end point was stent thrombosis. The Cox proportional hazard model was used to assess the adjusted association between the stent type and the follow-up outcome. Results: From 949 patients (66.3% male, mean age =59.48 ± 10.46 y) with 1,018 treated lesions, 591 patients (630 lesions, 65.1% male, mean age = 59.24 ± 10.23 y) received the PROMUS ™ stent and 358 patients (388 lesions, 68.2% male, mean age = 59.88 ± 10.83 y) were treated with the BioMatrix ™ stent. Before adjustment, the rate of the primary end points was 3.2% and 3.4% in the EES and BES, respectively (p value = 0.925, HR (EES to BES) = 1.035, 95% CI: 0.50 to 2.13). The rate of stent thrombosis was 2% and 1.7% in the EES and BES, respectively (p value = 0.698). After adjustment on confounder variables, there was no statistically significant difference in major adverse cardiac events between the PROMUS ™ stent and the BioMatrix ™ stent (p value = 0.598, HR (EES to BES) = 0.817, 95% CI: 0.39 to 1.73). Conclusion: At 1 year's follow-up, the BES and EES showed similar safety and efficacy rates in the patients undergoing percutaneous coronary intervention with a relatively low rate of adverse events in the 2 groups.

Mitral regurgitation (MR) is a common valvular lesion in the general population with considerable impact on mortality and morbidity. The MitraClip System (Abbot Laboratories, Abbot Park, IL, USA) is a novel percutaneous approach for treating MR which involves mechanical edge-to-edge coaptation of the mitral leaflets. We present our initial experience with the MitraClip System in 5 patients. In our series, the cause of MR was both degenerative and functional. Two patients received two MitraClips due to unsatisfactory results after the implantation of the first clip. Acute procedural success was seen in 4 patients. Blood transfusion was required for 2 patients. All the patients, except one, reported improvement in functional status during a 2-month follow-up period. Our initial experience with MitraClip implantation indicates that the technique seems feasible and promising with acceptable results and that it could be offered to a broader group of patients in the near future.

Background: Clinical trials of revascularization have routinely under-enrolled elderly subjects. Thus, symptom relief and improved survival might not apply to elderly patients, in whom the risk of mortality and disability from revascularization procedures seems to be high and co-morbidity is more prevalent. The present case control study was performed to draw a comparison in terms of the procedural success, procedural and in-hospital complications, and major adverse cardiac events (MACE) in a one-year follow-up of octogenarians (age ≥ 80 years) with a selected matched younger control group in the Tehran Heart Center Angioplasty Registry., Methods: According to the Tehran Heart Center Interventional Registry of 9, 250 patients with a minimum follow-up period of one year between April 1993 and February 2010, 157 percutaneous coronary intervention (PCI) procedures were performed in 112 octogenarians. Additionally, 336 younger patients (459 PCI procedures) were selected from the database as the propensity-score matched controls., Results: There were 147 (93.6%) and 441 (96.1%) successful PCI procedures in the elderly group and control group, respectively (p value = 0.204). Procedural complications were seen in 5 (3.2%) of the elderly group and 16 (3.5%) of the control group (p value = 0.858). Totally, 7 (6.3%) in-hospital complications occurred in the elderly group and 22 (6.8%) in the control group (p value = 0.866). One-year MACE was seen in 9 (9.1%) of the elderly and 18 (5.8%) of the control group (p value = 0.26)., Conclusion: Procedural success and complications, in-hospital complications, and one-year MACE were not significantly different between our two study groups. Therefore, age alone should not be used as the sole criterion when considering revascularization procedures. Furthermore, PCI should not be refused in octogenarians if indicated.