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Background: This article introduces the first national guidelines for the management including diagnosis, treatment, and secondary prevention of acute coronary syndrome (ACS) in Iran. Materials and Methods: The members of the guideline development group (GDG) were specialists and experts in fields related to ACS and were affiliated with universities of medical sciences or scientific associations in the country. They carefully examined the evidence and clinical concerns related to ACS management and formulated 13 clinical questions that were sent to systematic review group who developed related evidence using Grade method. Finally the GDG developed the recommendations and suggestions of the guideline. Results: The first three questions in the guideline focus on providing recommendations for handling a patient who experience chest pain at home, in a health house or center, during ambulance transportation, and upon arrival at the emergency department (ED) as well as the initial diagnostic measures in the ED. Subsequently, the recommendations related to the criteria for categorizing patients into low, intermediate and high-risk groups are presented. The guideline addressed primary treatment measures for ACS patients in hospitals with and without code 247 or having primary percutaneous coronary intervention (PCI) facilities, and the appropriate timing for PCI based on the risk assessment. In addition, the most efficacious antiplatelet medications for ACS patients in the ED as well as its optimal duration of treatment are presented. The guideline details the recommendations for therapeutic interventions in patients with ACS and acute heart failure, cardiogenic shock, myocardial infarction with nonobstructive coronary arteries (MINOCA), multivessel occlusion, as well as the indication for prescribing a combined use of anticoagulants and antiplatelet during hospitalization and upon discharge. Regarding secondary prevention, while emphasizing the referral of these patients to rehabilitation centers, other interventions that include pharmaceutical and nonpharmacological ones are addressed, In addition, necessary recommendations for enhancing lifestyle and posthospital discharge pharmaceutical treatments, including their duration, are provided. There are specific recommendations and suggestions for subgroups, such as patients aged over 75 years and individuals with heart failure, diabetes, and chronic kidney disease. Conclusion: Developing guidelines for ACS diagnosis, treatment and secondary prevention according to the local context in Iran can improve the adherence of our health care providers, patients health, and policy makers plans.

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BACKGROUND: The National Persian Registry of Cardiovascular Disease (N-PROVE) has been established to provide a comprehensive database of cardiovascular diseases in the Iranian community for further investigations and to develop national guidelines for the diagnosis, treatment, and prevention of cardiovascular disease (CVD). As with most clinical registries, a quality control audit is necessary to ensure a comprehensive and accurate registry; the current study aims to assess the validity and quality of the N-PROVE/Angiography/Percutaneous Coronary Intervention (PCI) registry. METHODS: The current cross-sectional quality assessment study serves as an example of data quality assessment in N-PROVE on a sample of patients registered in the N-PROVE/Angiography/PCI registry since 2020. Accordingly, data of 194 patients, including comorbidities, angiography, and angioplasty characteristics, were collected from the N-PROVE/Angiography/PCI registry as the main database and reevaluated by a panel consisting of a cardiologist and two coronary intervention fellowships as a test database. RESULTS: The quality control of the population-based healthcare database, the N-PROVE/PCI, revealed that the average error rate in terms of comorbidities, angiography characteristics, angioplasty characteristics, and in total were 3.8%, 2.3%, 3%, and 3.03%, respectively. CONCLUSION: According to the findings of this study, the N-PROVE/PCI registry had an average error of less than 4% in the assessed dimensions, including comorbidities, angiography, and angioplasty characteristics. Therefore, this registry appears valid and may be used for contemporary epidemiological studies.

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BACKGROUND: The coronary slow flow/no-reflow phenomenon (CSF/NRP) is a common complication of emergency percutaneous coronary intervention (PCI) for ST-elevated myocardial infarction (STEMI). Its long-term prognostic value, however, remains unclear. This study investigated the long-term outcome and prognostic value of CSF/NRP after emergency PCI for STEMI. METHODS: This retrospective, multicenter registry-based cohort study was conducted in STEMI patients who underwent emergency PCI between 2015 and 2016. Incidence of in-hospital mortality, major adverse cardiac and cerebrovascular events (MACCEs), and all-cause mortality during long-term follow-up were compared between CSF/NRP patients and the normal flow group. Cox proportional-hazards regression model was performed to identify the predictive impact of CSF/NRP in short- and long-term outcomes. RESULTS: A total of 649 STEMI patients were included in the study, of whom 193 (29.7%) developed CSF/NRP following emergency PCI. The CSF/NRP group had a higher incidence of in-hospital mortality than the non-CSF/NRP group (8.2 vs. 4.3%, P  = 0.04). All-cause mortality incidence was also higher in the CSF/NRP group during 5-year follow-up (22.2 vs. 16.2%, P  = 0.04). The Cox proportional hazards model adjusting for demographic and clinical variables identified the NRP as an independent predictor of 5-year cardiac mortality [hazard ratio: 1.89; 95% confidence interval (CI): 1.07-3.31; P  = 0.02]. In a landmark analysis, no difference was seen in overall mortality among the two study groups between 1 month and 5-year follow-up (hazard ratio: 1.33; 95% CI: 0.80-2.21, P -value: 0.23). Kaplan-Meier analysis showed lower 3-year cumulative MACCE-free survival in the CSF/NRP group compared with the normal flow group ( P  = 0.02). CONCLUSION: CSF/NRP in STEMI patients is associated with a worse short- and long-term prognosis. These results, however, are mostly related to the acute phase, and CSF/NRP had limited influence on clinical outcomes in early survivors of STEMI.

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BACKGROUND AND AIMS: The contribution of ultra-processed foods (UPFs) to daily energy intake and, therefore, their health effects may vary between countries. We aimed to investigate the association between UPFs and the incidence risk of cardiovascular events (CVEs) and cardiovascular mortality in the Isfahan cohort study. METHODS AND RESULTS: In 2001, 6504 participants aged ≥35 years were enrolled and followed until 2017. Dietary intake was assessed using a validated food frequency questionnaire, and the NOVA system was applied for UPF classification. Any new case of CVE, including fatal and non-fatal myocardial infarction (MI) or stroke, unstable angina (UA), and CVD death, was recorded. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated through Cox proportional hazards regression models. A total number of 819 CVE, 164 MI, 348 UA, 172 strokes, and 181 cardiovascular deaths were recorded during 61352.5 person-years of follow-up. The median (IQR) of UPF consumption was 2.47 (1.00-5.23) times/week. In the fully adjusted model, individuals in the fourth quartile of UPFs had no higher risk for incident MI and UA (HR = 1.12, 95% CI: 0.87, 1.46; P for trend = 0.364), stroke (HR = 0.93, 95% CI: 0.58, 1.46; P for trend = 0.601), cardiovascular mortality (HR = 0.95, 95% CI: 0.61, 1.47; P for trend = 0.596), and CVE (HR = 1.08, 95% CI: 0.88,1.34; P for trend = 0.515) in comparison with those in the first quartile. CONCLUSION: This mid-term prospective cohort study provides no evidence for a significant association between UPF and CVE risk. Longer studies are required to confirm this association.

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Objective: Obesity is a known risk factor for diabetes, but the effect of weight changes on the incidence of diabetes is not yet determined. This study aims to evaluate the long-term effects of weight change [based on body mass index (BMI)] on the incidence of diabetes mellitus (DM) in a middle eastern population. Method: In the Isfahan Cohort Study (ICS) 6504 adults equal or greater than 35 years of age were recruited at 2001 and were followed until 2013. Absolute BMI changes (ΔBMI) were calculated by subtracting the baseline BMI from the BMI measured at follow-ups. To compare participants with different baseline BMI easier, relative changes in BMI were quantified as the percentage of changes from baseline. DM was assessed based on standard definitions. Multivariable Cox regression was used to determine the association between ΔBMI and the incidence of diabetes. Results: During follow-ups, 261 new cases of diabetes were recorded, with an IR of 3401.29 per 100,000 P-Y. The highest number of new cases of type 2 DM belongs to participants with overweight and obesity who had minimal BMI changes (less than 5% of their baseline BMI limits; 42 and 38 new cases, respectively). Participants who were obese at baseline and had lost more than 10% or gained 5-10% of baseline BMI were in the groups with the highest IR [360.05-95% CI (239.3-541.8) and 322.39-95% CI (178.5-582.1) respectively]. There was no significant association between BMI changes and the incidence of DM in the participants with normal BMI, overweight, and obesity at baseline in cure and adjusted models. Conclusions: This study showed there was no significant association between diabetes mellitus incidence and BMI changes.

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BACKGROUND: Coronavirus disease of 2019 (COVID-19) is associated with venous thromboembolism (VTE), not only during hospitalization but also after discharge, raising concerns about anticoagulant (AC) use for post-discharge COVID-19 patients. We aimed to systematically review the current literature on the possible benefits or risks regarding extended thromboprophylaxis. MAIN BODY: We searched related databases from December 1, 2019, to October 6, 2022, including studies on the necessity, duration, and selection of the ideal AC regarding extended thromboprophylaxis for post-discharge COVID-19 patients. The screening of the selected databases led to 18 studies and 19 reviews and guidelines. Studies included 52,927 hospitalized COVID-19 patients, with 19.25% receiving extended thromboprophylaxis. VTE events ranging from 0 to 8.19% (median of 0.7%) occurred in a median follow-up of 49.5 days. All included studies and guidelines, except four studies, recommended post-discharge prophylaxis after an individual risk assessment indicating high thrombotic and low bleeding risk. Studies used risk assessment models (RAMs), clinical evaluation, and laboratory data to identify COVID-19 patients with a high risk of VTE. IMPROVE-DD was the most recommended RAM. Direct oral anticoagulants (DOACs) and low molecular weight heparins (LMWHs) were the most used AC classes. CONCLUSIONS: Post-discharge prophylaxis for COVID-19 patients is recommended after an individual assessment. The IMPROVE-DD model can help predict VTE risk. After distinguishing patients who need post-discharge AC therapy, DOACs for 30-35 days and LMWHs for 40-45 days can be the drug of choice. Further studies, particularly the results of the ongoing randomized controlled trials (RCTs), are required. Also, to properly handle such patients, every physician should consider lifestyle modification in addition to pharmacological treatment for post-discharge VTE prophylaxis.

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Background: Despite recognizing the traditional coronary artery disease (CAD) risk factors, some secondary factors, such as opioid substance abuse, have to be considered. We aimed to assess the relationship between opioid consumption and emergency percutaneous coronary intervention (PCI) revascularization results, according to Thrombolysis in Myocardial Infarction (TIMI) flow and in-hospital survival outcomes in ST-elevation myocardial infarction (STEMI) patients. Materials and Methods: This case-control study was conducted on 186 patients (93 patients in each group) with acute STEMI, who were referred to Chamran Heart Center, Isfahan, Iran. Opioid addiction was diagnosed by patients' records and confirmed by conducting an interview based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria. Patients in both groups were evaluated and compared for angioplasty results based on the TIMI flow grade and in-hospital cardiovascular events and complications. Results: Ninety-one patients (97.84%) of each group were male, and opioid-addicted patients were younger than the non-opioid users (52.95 9.91 vs. 57.90 12.17, P = 0.003). Among the CAD risk factors, prevalence of dyslipidemia was significantly higher in non-opioid users, whereas cigarette smoking was higher in opioid-addicted patients (P < 0.050). There was no significant difference between the two groups regarding pre- and post-procedural myocardial infarction complications as well as mortality rate (P > 0.050). Also, there were no significant differences between the opioid and non-opioid users regarding TIMI flow grading, and successful PCI rate based on achieving TIMI III was 60.21% versus 59.1% in opiate-dependent and non-opioid users, respectively (P = 0.621). Conclusion: Opioid addiction has no effects on post-PCI angiographic results and in-hospital survival outcomes in STEMI patients which undergoing emergency PCI.

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INTRODUCTION: Ticagrelor monotherapy after short-term (1-3 months) dual antiplatelet therapy (DAPT) with aspirin and ticagrelor can reduce bleeding without increasing ischemic events after percutaneous coronary intervention (PCI). However, its effect in diabetic and non-diabetic individuals has not been evaluated as a meta-analysis so far. METHOD: This systematic review and meta-analysis were conducted covering PubMed, ISI Web of Science, and Scopus without date restrictions for English published clinical trials. The authors searched the mentioned databases, wherein the screening led to 151 studies, of which 40 were assessed for eligibility, and finally, three studies were included. These trials compared ticagrelor monotherapy after a short duration of aspirin plus ticagrelor with conventional 12 months DAPT. RESULTS: The results showed that the risk of major bleeding (based on Bleeding Academic Research Consortium (BARC) type 3 or 5) for ticagrelor monotherapy subjects was lower in both diabetics and non-diabetics. It was especially significant in non-diabetic patients (HR 95%CI: 0.79(0.64, 0.98); p=0.029). In cardiovascular events assessment, the pooled estimate on cardiac deaths was significantly lower in diabetic subjects treated by ticagrelor monotherapy (HR 95%CI: 0.71(0.51, 1); p=0.05), while this reduction was not significant for non-diabetics (p=0.843) in comparison to patients treated by 12 months DAPT. However, there was no significant decrease or rise in myocardial infarction (MI) and ischemic stroke in patients treated by short-term DAPT strategy. CONCLUSION: In conclusion, discontinuing aspirin after short-duration DAPT could minimize the incidence of cardiac death and BARC type 3 or 5 bleeding in diabetic and non-diabetic patients who underwent PCI, with no increase in MI and ischemic stroke.

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INTRODUCTION: The use of allopurinol has shown promising outcomes in reducing oxidative processes responsible for atherogenic-related cardiovascular events. The current study aims to assess the effects of high-dose allopurinol on the post-revascularization coronary blood flow and inflammatory biomarkers in patients with non-ST segment elevated myocardial infarction (NSTEMI). METHOD: Eighty NSTEMI patients were randomly divided into two groups: the intervention group (n=40), medicated with a high loading dose of 600 mg allopurinol before the coronary angiography, and the control group (n=40), treated with a placebo. The highly sensitive C-reactive protein (hs-CRP) was measured at baseline and within 24 hours after the cardiac interventions and compared between the case and control groups. Post percutaneous coronary intervention (PCI) Thrombolysis in Myocardial Infarction (TIMI) flow grading was also evaluated as a revascularization endpoint. RESULTS: The two groups of the study were similar in terms of demographic, clinical, laboratory, and angiographic characteristics (P-value>0.050). The assessed TIMI flow was similar between the cases and the controls both prior to (P-value=0.141) and after (P-value=0.395) the coronary angioplasty. The hs-CRP (P-value=0.016) was significantly higher in the control group. Post-angiographic assessment of hs-CRP revealed an insignificant difference between the groups (P-value=0.104). CONCLUSION: In conclusion, premedication with a high dose of allopurinol in NSTEMI patients did not affect the inflammatory biomarker or the revascularization endpoint.

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INTRODUCTION: In recent years, transradial cardiac catheterization has become the preferred method. However, it can result in a significant complication known as radial artery occlusion (RAO). The medical management of RAO remains controversial, especially with the emergence of novel oral anticoagulants. Nevertheless, there is limited data on the use of these agents for treating RAO, which is the focus of this study using apixaban. METHOD: This pilot double-blinded randomized clinical trial involved 30 patients who developed RAO following transradial coronary angiography. The patients were randomly assigned to receive either apixaban (2.5 mg twice daily) or a conservative approach for 30 days. Doppler ultrasonography was performed at baseline and at the end of the intervention to assess radial artery diameter and the resolution of arterial patency. Demographic, medical, medication, and clinical characteristics were collected. RESULTS: The mean age of the studied population was 59.43±12.14 years, and the majority were males (60%). Radial artery resolution was observed in 21 (70%) patients, independent of medication use. There was no significant association between resolution and age (P-value=0.62), gender (P-value=0.74), body mass index (P-value=0.23), smoking (P-value=0.64), diabetes (P-value=0.999), hypertension (P-value=0.74), statins (P-value=0.999), antiplatelet therapy (P-value=0.999), length of angiography (P-value=0.216), or follow-up arterial diameter (P-value=0.304). Recanalization occurred in 13 (86.7%) cases in the apixaban treatment group, compared to 8 (53.3%) individuals in the control group, indicating a significant difference (P-value=0.046). CONCLUSION: The study findings suggest no demographic, medical, medication, or clinical factors were associated with arterial recanalization. However, a one-month treatment with apixaban at a dose of 2.5 mg twice daily appeared to be effective.

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INTRODUCTION: The generation of reactive oxygen species, which is induced by the activation of the xanthine oxidase (XO) enzymatic system, is one of the primary causes of ischemia-reperfusion injury for an ischemic heart. Allopurinol, as an XO inhibitor, plays an inhibitory role in free radical production in ST-elevation myocardial infarction (STEMI) patients. The aim of this study is to evaluate the impact of allopurinol pre-treatment on post-revascularization outcomes in patients admitted with STEMI. METHOD: Ninety patients with acute STEMI were enrolled in this randomized double-blind clinical trial and divided into two equal groups. The allopurinol group received a 600 mg allopurinol loading dose before the emergency PCI, and the control group received a placebo medication of the same shape. Thrombolysis in Myocardial Infarction (TIMI) flow, ECG changes, troponin level, and the occurrence of major cardiac events (MACE) during a 1-month follow-up were assessed. RESULTS: In the end, 81 patients were analyzed. The mean age of the patients was 59.52(11.31) and 61.3(9.25) in the allopurinol and control groups, respectively (p = 0.49). The troponin level 48 hours after the PCI and ST-elevation regression showed no significant difference between the groups [(p = 0.25) and (p = 0.21), respectively]. TIMI flow had improved in the allopurinol group compared to the placebo (p = 0.02). The PCI success rate was 78.6% and 61.5% in the case and control groups, respectively (p = 0.09). MACE and other clinical outcomes were similar between the groups (p > 0.05). CONCLUSION: This study revealed that allopurinol pre-treatment could improve TIMI flow in patients undergoing primary or rescue PCI in an acute STEMI setting.

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OBJECTIVE: Trans-palmar access is a novel, safe, and feasible technique for coronary artery angiography wherein its appropriate anesthetic methods is still concerned. In this study, we aimed to evaluate the pain severity, satisfaction, and possible complications with local ulnar nerve anesthesia through both distal and proximal forearm in patients undergoing trans-palmar coronary angiography. METHODS: This was a randomized clinical trial performed on 60 patients who were candidates for trans-palmar coronary angiography. The patients were randomized into 2 equal groups as proximal and distal approaches (those who received the same dose of subcutaneous lidocaine (2%) in the proximal and distal of forearm, respectively). Pain intensity at different times, duration of anesthesia, patient satisfaction, and occurrence of complications were evaluated. RESULTS: The mean age of the patients was 59.45±7.09 years, and, of them, 34 (61.8%) were men. Pain severity with the proximal anesthesia approach was significantly higher than that in the distal group at the time of puncture (5.39±0.73 vs. 2.30±0.60, p=0.001). Over time and immediately after the procedure and at discharge, the mean pain severity in the proximal group was significantly less than in the distal group (p<0.050). The proximal group also had a longer duration of anesthesia (67.14±11.58) than the distal group (53.52±8.06) (p=0.001). No differences were observed in terms of patient satisfaction and complications (p>0.050). CONCLUSION: Using the proximal ulnar nerve anesthesia approach was associated with a delayed onset and longer anesthesia than the distal method.

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Background: Determining cardiovascular disease (CVD) research priorities is essential given the high burden of these diseases, limited financial resources, and competing priorities. This study aimed to determine the research priorities in CVD field in Iran using standard indigenous methods. Materials and Methods: An extensive search was done in relevant international and national studies. Then, an indigenous standard multistage approach based on multicriteria decision analysis steps was adapted to local situation and implemented. This process included forming a working group of experts in priority setting methodology, identifying the context and prioritization framework, discussing the methodology with the National Network of CVD Research (NCVDR) members who ultimately determined the priority research topics, weighted topics criteria, ranked topics, and reviewed all determined research priorities for final report. Results: Thirteen cardiovascular research priorities were determined by the NCVDR members. The first five priorities based on their scores include studies in hypertension, prevention and control of ischemic heart disease (IHD) and its risk factors, burden of IHD, Registration of CVDs, and COVID-19 and CVDs. Conclusion: Cardiovascular research priorities were determined using a standard indigenous approach by national experts who are the NCVDR members. These priorities can be used by researchers and health decision makers.

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The Severe acute respiratory syndrome coronavirus-2 (SARS-COV-2) created a global pandemic that continues to this day. In addition to pulmonary symptoms, the virus can have destructive effects on other organs, especially the heart. For example, large pericardial effusion has been observed as a critical and life-threatening finding in Coronavirus disease of 2019 (COVID-19) patients. In this case report based systematic review, we review the reports of moderate to severe pericardial effusion associated with tamponade physiology. Direct cardiomyocyte and pericardium invasion, inflammation and cytokine storms and oxidative stress due to acute respiratory distress syndrome, are the pathogenesis of this phenomenon. The results showed that the manifestations of this finding are variable. Pericardial effusion can be seen as a delayed complication, accompanied by myocarditis or pericarditis, isolated, or with acute respiratory distress syndrome. In most patients, emergency percutaneous pericardiocentesis was performed, and fluid analysis was often exudative in 3 pattern of hemorrhagic, serous, and serosanguinous. Medical treatment and follow-up are recommended, especially in cases of pericarditis.

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BACKGROUND: With the onset and spread of the COVID-19 pandemic, the hospitalization and treatment of noncovid patients were dramatically affected. The aim of this study is to evaluate the electrophysiology (EP) lab activity in a referral center in Iran during the COVID-19 era. METHODS: A cross-sectional descriptive survey was conducted on EP lab activity in Shahid Chamran Heart Center, Isfahan, Iran. Two periods of COVID-19 occurrence peaks in Iran were compared with same date in 2019. Information was collected on number of diagnostic and therapeutic electrophysiology studies (EPSs) and implantation of intracardiac devices such as permanent pacemaker (PPM), implantable cardioverter defibrillator (ICD), and cardiac resynchronization therapy (CRT). RESULTS: In the first peak of COVID-19 pandemic, both of EPSs and intracardiac device implantations decreased by 80% compared to the same period in 2019. The most common type of device implanted during this period was PPM (70%); however, at the time of control, the ICD (73%) was the most common. Paroxysmal supraventricular tachyarrhythmia (PSVT) was the best indication for diagnostic and therapeutic EPSs in covid and control periods. In the second peak of prevalence of COVID-19 virus infection in Iran, 6% and 36% decreases in device implantations and EPSs were seen, respectively. During this period, the number of procedures increased, although it was still lower than in 2019. CONCLUSION: A significant reduction in the EP lab activity has been observed during both the COVID-19 pandemic peaks.

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OBJECTIVE: Distal radial artery access or trans-snuffbox access (TSA) is a novel, safe, and feasible technique for coronary artery interventions wherein its vascular hemostasis is still concerned. So, this study aimed to compare two homeostasis methods comprising manual and mechanical compression approaches in patients undergoing coronary angiography (CAG) via TSA. METHODS: In a prospective nonrandomized clinical trial, a total of 80 patients undergoing diagnostic CAG by TSA were divided into two equal groups: manual compression and mechanical compression (using radial TR band), the main end point of which was primary hemostasis time. Other variables were patient satisfaction, puncture site pain severity, hospitalization time, and local neurovascular complication during the 30-day follow-up. RESULTS: The mean age of the patients was 57.1±8.0 years, with 40 of them (54.1%) being male. The primary hemostasis time was significantly shorter in the manual compression approach [15.0±5.9 minutes with median 15 (9-20)] than in the TR band group [25.7±4.9 minutes with median 25 (20-30)] (p<0.001). No significant difference was noted in the patient's satisfaction and puncture site pain severity as well as hospitalization time between the two methods (p>0.050). The neurovascular complication, including hematoma, numbness, and dRA occlusion, rates had also no significant difference between the two groups (p>0.050). CONCLUSION: The manual compression approach on the puncture site reduces hemostasis time in patients undergoing CAG via TSA when compared with the mechanical compression method.

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BACKGROUND: With the onset of the coronavirus disease-2019 (COVID-19) pandemic, hospitalization and treatment of non-covid patients decreased worldwide. The aim of this study is to evaluate the admission and treatment of patients with coronary artery diseases (CADs) by examining coronary Cath labs activities in some centers of Iran during the COVID-19 period. METHODS: A retrospective, multi-center survey was conducted in four cites in Iran which participated in National Persian Registry Of CardioVascular diseasE (N-PROVE). Two periods of COVID-19 occurrence peak in Iran were compared with the same date in 2019. Information was collected on the number of diagnostic and therapeutic coronary catheterizations in both stable ischemic heart diseases (SIHDs) and acute coronary syndrome (ACS) settings. RESULTS: In the first peak of COVID-19 pandemic, coronary angiographies and angioplasties decreased by 37 and 38% compared to the same period in 2019, respectively. The most common indication for coronary angiography during this period was ACS [especially ST-Segment Elevation Myocardial Infarction (STEMI)]; however, at the time of peak decrease, the SIHDs were the most. In the second peak of COVID-19 pandemic in Iran, 34% and 27% decrease in diagnostic and therapeutic coronary procedures were seen, respectively. During this period, the number of elective admissions increased, although it was still lower than that in 2019. The tendency to rescue percutaneous coronary intervention increased in most centers during the COVID-19 era, especially in the second peak. CONCLUSION: A significant reduction in the coronary Cath lab activity has been observed during the COVID-19 pandemic that can indicate an increased risk of cardiovascular mortality and morbidity.

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Trans-palmar catheterization has been considered to be safe and feasible and choosing a reliable hemostasis method is essential to confirm it. The aim of our study was to compare the efficacy and safety of three hemostasis approaches containing ulnar TR band, manual compression and wrist hyperextension in patients undergoing trans-palmar coronary angiography (CAG). In a non-randomized clinical trial, a total of 106 patients undergoing diagnostic CAG by tarns-palmar access were divided into three groups: ulnar TR band, manual compression and wrist hyperextension. Duration of primary hemostasis, patient satisfaction, puncture site pain severity, hospitalization time and local neuro-vascular complication were evaluated and compared in hospital and 30 days follow-up. The mean age of the patients was 62.9 ± 7.4 years and 72 patients (67.9%) were male. Primary hemostasis time was significantly shorter in hyperextension (11.5 ± 2.10 min) and manual compression groups (12.3 ± 2.20 min) than with TR band group (24.7 ± 10.25 min) (p value < 0.0001). Patient's satisfaction was higher in hyperextension approach (9.4 ± 0.65) than manual compression (8.8 ± 0.79) and TR band group (8.2 ± 0.90) (p value < 0.0001). The most pain was seen in the TR band and the less in hyperextension group until 4 h after the procedure (p value < 0.0001). Hematoma, numbness and ulnar artery occlusion as well as hospitalization time did not have significant statistical differences (p value > 0.05). In conclusion, between three methods of hemostasis in trans-palmar catheterization, hyperextension approach is the preferred method because of effectiveness, safety and less time consuming hemostatic method compared others.

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With the outbreak of the second peak of COVID-19 in many countries of the world, the symptoms and complications of this disease has received a great deal of attention. One of the most important known complications of severe acute respiratory syndrome coronavirus 2 is the occurrence of venous thromboembolic events, especially in critically ill patients who are hospitalized in the intensive care unit. The pathology of this event is complex and multifactorial, but the main problem now is the timely diagnosis of these phenomena, which can reduce the mortality and morbidity of patients. Deterioration of clinical condition in patients with severe acute respiratory syndrome coronavirus 2 infection along with increased coagulation markers can increase clinical suspicion of venous thromboembolic events. Imaging techniques, especially computed tomography pulmonary angiography, can well solve this puzzle and lead to timely treatment of these patients.

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As the COVID-19 pandemic continues, more information on the nonrespiratory effects of the coronavirus is obtained. Cardiovascular complications, especially acute coronary syndromes, are rare. However, they prove to be effective factors in the mortality rate of COVID-19 subjects. Acute ST-elevation myocardial infarction with a special angiographic pattern in the form of extensive and multivessel thrombosis, regardless of atherosclerotic plaques, has posed a new therapeutic challenge. This has been associated with an increase in the incidence of stent thrombosis. Hypercoagulation, due to severe inflammation, is the main pathology of this phenomenon. Technically, percutaneous coronary intervention with aspiration thrombectomy and injectable antiplatelet are the mainstay of treatment for these patients. In addition, it is vital that appropriate antiplatelet and ischemia treatment after the intervention be taken into account.

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