12 Tabestan 1386 Summer 2007 8 2 82 M. M. Peighambari MD, A. Shahmohammadi Mousavi MD, M. Madani MD, N. Zafaranloo MD* and L. Zahedi MD* We enrolled 220 patients who had been hospitalized for an acute coronary syndrome (unstable angina, non-ST elevation MI) within the preceding 30 days and compared 20 mg of simvastatin daily (group B) with patients not receiving that (group A). The primary end point was a composite of deaths, myocardial infarction, documented unstable angina requiring rehospitalization, and urgent revascularization (performed at least 30 days after randomization). Follow-up lasted for one month. Median LDL cholesterol level achieved during treatment was similar; 90 mg/dl in group B and 87.1 mg/dl in group A (P> 0.05). Chi-square and t-test estimates of the rate of the documented unstable angina requiring hospitalization were 26.4 percent in group B and 31 percent in group A (odds ratio= 4.5; 95% CI= 2.4-6; P= 0.01). Revascularization and early angiography was 20.9 percent in group B and 48.2 percent in group A (odds ratio= 3.5; 95% CI= 1.9-6.3; P< 0.001). Group B had a lower risk of myocardial infarction after admission due to acute coronary syndrome (odds ratio= 4; 95% CI= 1.1-6; P<0.001), reflecting a reduction in mortality (0.9% in group B and 2.7% in group A), but this difference was not significant (P= 0.6), at least partially because of the relatively small number of mortalities in this study (1.8%). Early use of simvastatin in ACS appears to decrease risk for cardiovascular events. We believe statin therapy should be initiated early (at the latest before hospital discharge) in all patients who have been hospitalized for acute coronary syndrome (Iranian Heart Journal 2007; 8 (2): 6-15). Early use of simvastatin in ACS appears to decrease risk for cardiovascular events. We believe statin therapy should be initiated early (at the latest before hospital discharge) in all patients who have been hospitalized for acute coronary syndrome (Iranian Heart Journal 2007; 8 (2): 6-15). acute coronary syndrome ■ blood lipids ■ statins ■ mortality ■ morbidity 83 Negar Salehi MD, Majid Maleki MD, Feridoun Noohi MD, Anita Sadeghpour MD, Mojdeh Nasiri Ahmad Abadi MD, S. Zahra Ojaghi Haghighi MD, Niloufar Samiei MD, Maryam Esmailzadeh MD and Goldis Malek PhD. Coronary artery disease is the most common etiology of disability and death in the world. We evaluated the efficacy of echocardiography in patients after myocardial infarction, as a diagnostic means for identifying risk of future cardiac events. This is a cross –sectional study on 150 patients admitted with acute myocardial infarction who were followed for three months. We compared the baseline wall motion score index (WMSI) accessed within the first 24 hours and the hemodynamic function as determined according to Killip’s classification in patients admitted with acute myocardial infarction to Shaheed Rajaie Cardiovascular Medical Center in Tehran, Iran. There was a positive correlation between WMSI determined immediately following admission in patients with acute myocardial infarction and good prognosis. Patients included in this study were grouped into four Killip’s classes: Class I (n=72 patients), Class II (n=58 patients), Class III (n=13 patients) and Class IV (n= 7 patients). Overall, patients with high WMSI were subclassified within higher Killip’s classes. Early mortality rate was greater in patients with both WMSI≥2 and a higher Killip’s class. Patients with anterior myocardial infarction (MI), WMSI≥2 and high Killip’s class had higher peak CPK-MB levels. Echocardiographic left ventricular WMSI obtained shortly after an acute myocardial infarction is an affordable and readily available technique, which provides important prognostic information regarding patients’ clinical outcome and prognosis. We conclude that patients presenting with high WMSI need early invasive procedures for improved prognosis (Iranian Heart Journal 2007; 8 (2): 16-21). wall motion score index ■ myocardial infarction ■ killip’s class 84 Mahmoud Ebrahimi MD and Saeed Bajouri MD Heparin is one of the current and necessary medications in acute myocardial infarction (MI). Given the narrow therapeutic dose and unpredictable pharmacokinetics of heparin, its anticoagulant effect should be measured precisely. Despite the widespread utilization of heparin in intermittent fixed doses and weight-independent IV administration, our data about the range of aPTT as a monitoring marker are quite limited. Thus we prepared this study to measure if the custom method fills the target therapeutic range. This cross-sectional study was performed on 144 patients admitted to our department with acute MI in 2004, who received heparin 5000 units q4h and had daily aPTT checked on three consecutive days. We chose the second day samples for this study, and the data were gathered by a checklist and analyzed with SPSS software. 12.5% of patients had aPTT levels in the therapeutic range, 6.2% of patients had a mean aPTT level above therapeutic range and remarkably, 81.3% of patients never achieved the therapeutic range. Our results also demonstrated that older age and female sex are associated with higher aPTT levels, and smoking unlike diabetes is associated with lower aPTT levels. Despite tolerability by patients and staff, the above findings necessitate reconsideration in the dose and interval of customary heparin administration (5000 unit IV q4h) and changing to continuous infusion method or use of low molecular weight heparins (Iranian Heart Journal 2007; 8 (2): 22-25). partial thromboplastin time ■ myocardial infarction ■ heparin 85 M. Hassanzadeh MD, R. Farid MD, M. Mahini MD, M. H. Ayati MD, F. Farid MD, A. Ranjbar MD and P. M. Nasiri MD Selenium (Se) is part of the enzyme glutathione peroxidase (GSH – Px) that plays an important role in the antioxidant defense of the body. Evidence has demonstrated that populations with low intake of selenium in the diet have a 2-3 fold risk of ischemic heart disease. Positive statistically significant correlations have been found between trace element concentrations (Cu, Zn, Se) of heart tissue with physiological parameters (CO: cardiac output, EF: ejection fraction) of the heart. Increased plasma concentration of TNF-α has been found in patients with coronary artery disease. Stressed myocardium activates pro-inflammatory cytokines, such as TNF-α, which produce abnormalities in myocyte contractile function. This study was done to determine the circulating levels of Cu, Zn, Se, IL- 6, TNF - α, and erythrocyte GSH - PX activity in two groups of patients with chronic coronary artery disease (CCAD), acute myocardial infarction (AMI) and normal individuals (IHD-free). Patients were divided into two groups: 25 with chronic CAD (CCAD) and 25 with acute myocardial infarction (AMI). The control group was 50 normal individuals that did not have any symptoms for IHD, and was gender and age-matched with the patients. Blood samples were collected during the first hours after the onset of chest pain in the acute MI group. Serum levels of Se, Cu, and Zn were determined by atomic absorption spectrometry, TNF-α and IL-6 were measured with ELISA and erythrocyte GSH-PX activity with Paglia and Valentine methods. In both groups of patients, there was a significant reduction of Se in the serum (82.36±11.31 micg/l in CCAD, 74.08±11.31 in AMI vs. 105±32.52 in control group, P-value=0.03). No statistically significant difference was found in Zn and Cu serum levels (0.98±0.22 and 112±18 in CCAD and 0.98±0.4 and 115±20 in AMI vs. 0.96±0.24 and 114±17 in control group). TNF-α titers showed a significant difference in AMI patients compared to CCAD and control groups (mean TNF-α level 37.44 pg/ml in CCAD, 914.32 pg/ml in AMI and 4.80 pg/ml in control group, P value 0.01). Serum levels of IL-6 in the two groups of CCAD and AMI patients were 3.28±15.55 and 472±207.88 pg/ml, respectively, compared to 1.28 pg/ml in the control group, P= 0.001) These findings confirm the previous studies and demonstrate that patients suffering from AMI exhibit a lower plasma concentration of selenium and TNF-α and IL - 6 significantly increase during the first hours of AMI. Selenium concentration of whole blood was lower in the two patient groups (CCAD, AMI) compared to the control group. GSH - PX activity has a strong inverse association with CAD (Iranian Heart Journal 2007; 8 (2): 26-29). AMI ■ CAD ■ selenium ■ zinc ■ copper ■ TNF- α ■ IL- 6■ GSH- PX 86 Mahmoud Mohammadzadeh Shabestari MD, Leila Alizadeh MD, Mehri Nikdoust MD, Fardin Mirblouk MD and Javad Mahmoodi The aim of this study was to evaluate effects of retrograde filling on the patency of significant (high-grade, >90%) coronary arterial stenosis. The basis of our study was a comparison between the first and the second angiography of 102 patients with at least a 3-month interval between the two angiographies. Seventy-four of the patients were male (72.5%) and twenty-eight were female (27.4%). The patients were between the ages of 40 and 75, and the mean patient age was 61. Patients were not classified in order of risk factors, and none of them had diabetes mellitus. All 102 patients were classified in two groups (A and B) in regard to the presence or absence of retrograde filling. Group A (34 patients) consisted of patients with retrograde flow of grade 3 (complete perfusion) or 2 (partial collateral flow), whereas patients with retrograde filling grade 1(barely detectable collateral flow) or 0 (no collateral flow) were put into group B (68 patients). In the second angiography, total occlusion occurred in the target vessels of 30 patients (88.24%) in group A and 12 patients (17.65%) in group B. Ninety percent occlusion and existence of antegrade flow was seen in 4 (11.76%) and 56 (82.35%) patients of group A and B, respectively. Results were analyzed through a Chi-square test. Total occlusion occurred in the patients with retrograde collateral flow significantly more than in patients without retrograde collateral vessels. (P=0.001). As the severity of obstruction leads to retrograde collateral development, significant retrograde collaterals cause earlier total vessel occlusion (Iranian Heart Journal 2007; 8 (2): 30-34). antegrade flow■ collateral artery■ coronary artery■ retrograde flow stenotic lesion■ VEGF 87 Maryam Esmaeilzadeh MD, Majid Malaki MD, Niloofar Samiei MD, Anita Sadeghpour MD, Fereidoun Noohi MD, Zahra M. Ojaghi MD and Ahmad Mohebbi MD The aim of this study was to evaluate the relation of symptoms to valve stenosis. The hemodynamic data were evaluated at rest and after exercise using exercise stress echocardiography. We prospectively studied hemodynamic data in 15 consecutive patients with moderate mitral stenosis (MS) who were in NYHA function class two or higher. Treadmill exercise stress echocardiography (Bruce protocol) was done (GE Vingmed CFM 800). Mitral valve area (by planimetry and PHT method), mean TMVG, peak TMVG, and PAP were measured in all the patients at rest and within 90 seconds after the termination of exercise. In 66.7% of patients with moderate mitral stenosis, the stenosis was hemodynamically significant regarding the increase in mean TMVG (2 times in comparison with rest, or more than 15mmHg) and PAP after exercise. Our results suggest that in patients with moderate mitral stenosis, hemodynamic response to exercise has better correlation with the degree of valve stenosis severity and the occurrence of symptoms. In these patients, exercise stress Doppler echocardiography is a noninvasive and reliable method to assess the mitral flow characteristics (Iranian Heart Journal 2007; 8 (2): 35-38). mitral stenosis■ stress echocardiography■ exercise 88 R. Parvizi MD, H. Javadzadeghan MD, A. Sajjadieh MD, S. Hassanzadeh PhD, H. Hakim MD and J. Samadikhah MD Myocardial bridge consists of muscle fiber bundles lining an epicardial coronary artery for a variable distance. Although myocardial bridge is associated with a benign prognosis, its presence has also been considered a cause of angina, myocardial infarction, malignant arrhythmia and sudden death. There is no general consensus about therapeutic strategies in symptomatic patients with myocardial bridge (medical therapy, coronary artery bypass surgery, coronary stenting, supra-arterial myotomy).We report results of surgery and long-term follow up in 26 patients who had disabling symptoms due to myocardial bridge refractory to medical therapy. From 1999 to 2004, among more than 18,800 coronary angiographies which were performed in our department, 290 (1.5%) cases had the angiographic diagnosis of myocardial bridge. From these, 26 (9%) patients underwent surgical myotomy for treatment of myocardial bridge causing significant systolic arterial compression. The patients (19 male, 7 female) had a history of typical chest pain and positive exercise test. All of them were examined with radionuclide study preceding angiography, which was positive for ischemia in 20 cases (76%). Coronary angiography and left heart catheterization revealed impaired blood flow due to myocardial bridge in left anterior descending artery in all patients and there was additional atherosclerotic stenosis of coronary arteries in 6 and mitral valve disease in one patient. Supra arterial myotomy was performed in all patients. There was no mortality or major intraoperative complication. Postoperative scintigraphic and angiographic studies demonstrated restoration of coronary blood flow and myocardial perfusion without significant residual compression of the artery, except in one patient who had recurrent anginal chest pain after operation and coronary angiography showed residual narrowing in the LAD despite myotomy. This patient underwent CABG of LIMA to distal LAD. During 7-81 months of follow-up (mean: 34.2± 21), only two patients had symptoms of angina which did not show significant residual compression, and symptoms were controlled by medical treatment. In conclusion, surgical relief of myocardial ischemia due to myocardial bridge can be accomplished with very low operative risk and excellent mid term results (Iranian Heart Journal 2007; 8 (2): 39-43). myocardial bridge¡ supra arterial myotomy¡ coronary artery bypass surgery ■ coronary angiography 89 F. Jalali, MD and K. O. Hajian-Tilaki*, PhD In addition to traditional cardiovascular risk factors, high levels of plasma homocysteine has been documented recently as independent risk factors for atherosclerosis. The probable mechanism is through endothelial dysfunction. Roughly 10% of the population with coronary artery disease (CAD) may have hyper-homocysteinemia. Since folic acid is a potential factor in lowering plasma homocysteine and dietary intake of folic acid is not sufficient, it needs to be prescribed to CAD patients as a supplement. The purpose of this study is to assess the effect of folic acid on plasma homocysteine levels and on morbidity in stable CAD patients. In this prospective interventional study, we recruited 52 stable CAD patients; the plasma levels of homocysteine, folic acid and vitamin B12 were measured. The morbidity-related indices (the number of sublingual TNGs per week, typical anginal chest pain per week, the number of cardiovascular-related hospitalizations in the previous 3 months, functional class and ECG changes) were determined. All patients received 2 mg oral folic acid daily for 3 months. At the end of the study, the level of homocysteine and morbidity were determined. Folic acid supplementation for 3 months was associated with a decrease in homocysteine level by 44% (P=0.000). We did not observe a significant change in levels of serum folic acid. There were significant declines in all morbidity indices including TNG consumption, frequency of chest pain, functional class and hospitalizations (P=0.001). The findings indicate that 2 mg folic acid orally daily for 3 months is associated with a decrease in homocysteine level and morbidity in CAD patients (Iranian Heart Journal 2007; 8 (2): 44-50). serum homocysteine ■ folic acid ■ morbidity ■ coronary artery disease 90 Jalal Vahedian MD, FIAS, *Ali Sadeghpour Tabaee MD, **Hossein Azarnik MD and **Niloufar Samiei MD heart thrombosis and pseudoaneurysm of the abdominal aorta. The patient was admitted to the surgical unit because of malaise, tachycardia, easy fatigability and fever. The patient had a history of long standing low-grade fever, weight loss, fatigue, long-term headaches and non-specific skin lesions of the lower extremities. One month previously, an echocardiographic examination had revealed a right ventricular mass, thought to be a thrombus in an unusual location. The patient had consequently undergone surgery, and pathologic examination had confirmed the mass to be a thrombus. When the patient was subsequently re-admitted to the emergency unit of our center with complaints of severe abdominal pain, fever, fatigue, sinus tachycardia and a pulsatile and tender abdominal mass, a right ventricular thrombus and a large pseudoaneurysm of the abdominal aorta were found on echocardiography and angiography, respectively. The patient underwent resection of the aortic aneurysm and aortoplasty and received immunosuppressive and anticoagulation therapy. The thrombus of the right ventricle disappeared 4 months later (Iranian Heart Journal 2007; 8 (2): 51- 55). Behçet’s disease■ cardiac thrombus■ aortic pseudoaneurysm 91 L. Ghandili MD1, A. R. Mahoori MD2 and N. Malekpour MD3 Pericardial defect is a rare congenital abnormality, and most of the presenting cases are reported from intraoperative or post-mortem diagnosis. We report a case (46 yr-old male) with a 2-year history of vague chest pain and dry cough. Chest roentgenography showed a mass in the supero-medial portion of the left lung without displacement of the heart. Computerized tomography supported the diagnosis of a cystic mass in the medial part at the lingula lobe of the left lung. Echocardiography was normal. He was operated for symptomatic pulmonary mass and intraoperative findings were complete absence of the left pericardium and a bronchogenic cyst of the lingual (Iranian Heart Journal 2007; 8 (2): 56-58). complete absence of pericardium ■ bronchogenic cyst ■ chest mass