Iranian Heart Association Iranian Heart Journal 27 4 2026 10 01 Relationship Between Left Ventricular Diastolic Dysfunction Echocardiographic Indices and SYNTAX Score in Triple-Vessel CAD: A Cross-Sectional Study 6 15 254161 EN Niloufar Akbari Parsa Cardiovascular Diseases Research Center, Department of Cardiology, Heshmat Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, IR Iran. 0000-0002-5280-9579 Amir Savarrakhsh Cardiovascular Diseases Research Center, Department of Cardiology, Heshmat Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, IR Iran. Salman Nikfarjam Cardiovascular Diseases Research Center, Department of Cardiology, Heshmat Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, IR Iran. 0000-0002-2531-479X Seyyed Aboozar Fakhr-Mousavi Cardiovascular Diseases Research Center, Department of Cardiology, Heshmat Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, IR Iran. Amir Aris Cardiovascular Diseases Research Center, Department of Cardiology, Heshmat Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, IR Iran. Arsalan Salari Cardiovascular Diseases Research Center, Department of Cardiology, Heshmat Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, IR Iran. Aseme Pourrajabi Cardiovascular Diseases Research Center, Department of Cardiology, Heshmat Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, IR Iran. Bahareh Gholami-Chaboki Cardiovascular Diseases Research Center, Department of Cardiology, Heshmat Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, IR Iran. Sorna Naseri Cardiovascular Diseases Research Center, Department of Cardiology, Heshmat Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, IR Iran. Journal Article 2025 05 05 Background: Whether left ventricular diastolic dysfunction (LVDD) relates to anatomic coronary disease burden remains uncertain. We examined the association between echocardiographic diastolic indices and the Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score among patients with triple-vessel coronary artery disease (CAD). Methods: We performed an analytical cross-sectional study of 153 consecutive patients with angiographically confirmed triple-vessel disease at the Dr Heshmat Rasht Heart Training Center (Iran) from 2022 through 2023. Eligible patients had blood pressure below 140/90 mm Hg and preserved systolic function; standard exclusions applied. We recorded demographics and cardiac risk factors and measured diastolic indices (left ventricular ejection fraction, E/A, average E/e′, left atrial volume index, deceleration time, tricuspid regurgitation velocity, septal and lateral e′, and left ventricular end-diastolic volume index). Coronary complexity was graded by the SYNTAX score (≤ 22, low and > 22, high). We used χ2, t, and Mann–Whitney tests and logistic regression (adjusted for age and sex; secondarily for diabetes and hyperlipidemia). Results: Of 153 patients, 68 (44.4%) had low SYNTAX scores and 85 (55.6%) had high SYNTAX scores. None of the diastolic echocardiographic parameters differed between SYNTAX score groups or were independently associated with high SYNTAX scores on multivariable analysis. In contrast, diabetes and hyperlipidemia were associated with high SYNTAX scores: diabetes adjusted odds ratio (aOR) 3.71 (95% CI, 1.84 to 7.50) and hyperlipidemia aOR 2.83 (95% CI, 1.31 to 6.10). Conclusions: In patients with triple-vessel CAD, echocardiographic indices of LV diastolic function were not associated with anatomic disease complexity, whereas diabetes and hyperlipidemia were. Larger studies across a broader spectrum of LVDD severity are warranted. (Iranian Heart Journal 2026; 27(4): 6-15)

https://journal.iha.org.ir/article_254161_59a3ceb8bc26a77bba1931235b4ff608.pdf

Iranian Heart Association Iranian Heart Journal 27 4 2026 10 01 Echocardiographic and Clinical Determinants of Atrial Fibrillation in Patients With Cardiovascular Disease: A Retrospective Study 16 24 254162 EN Amin Esmaeilnia Shirvani Cardiovascular Research Center, Mazandaran University of Medical Sciences, Sari, IR Iran. 0009-0002-5939-8765 Mahmood Moosazadeh Gastrointestinal Cancer Research Center, Noncommunicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, IR Iran. 0000-0002-5452-514X Maryam Nabati Department of Cardiology, Faculty of Medicine, Cardiovascular Research Center, Mazandaran University of Medical Sciences, Sari, IR Iran. 0000-0002-2700-4074 Journal Article 2025 05 17 Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting millions of individuals worldwide. This study aimed to evaluate the epidemiological, clinical, and echocardiographic characteristics of patients with AF in a regional population. Methods: In this retrospective study, 652 patients admitted to a tertiary cardiac center were divided into AF and non-AF groups. Demographic and clinical data were collected. Transthoracic echocardiography was performed by a cardiologist. The 2 groups were compared to establish associations and potential predictor factors for AF. Results: Each of the 2 groups consisted of 326 patients. Significant differences were observed between the 2 groups in terms of ejection fraction (P = .001), LA enlargement (P = .001), mitral regurgitation (P = .001), tricuspid regurgitation (P = .001), and pulmonary artery hypertension (P = .001). The univariable logistic regression model revealed a significant association between AF and hypertension (OR, 1.429; 95% CI, 1.050 to 1.945; P =. 023), heart failure (OR, 1.494; 95% CI, 1.049 to 2.128; P = .026), reduced ejection fraction (OR, 2.276; 95% CI, 1.490 to 3.476; P = .001), and left atrial enlargement (OR, 3.751; 95% CI, 2.559 to 5.499; P = .001). The multivariable logistic regression model revealed a significant association between AF and hypertension (OR, 1.574; 95% CI, 1.047 to 2.367; P =.029) and left atrial enlargement (OR, 2.080; 95% CI, 1.327 to 3.261; P = .001). Conclusions: This study revealed significant associations between atrial fibrillation and clinical and echocardiographic factors, especially hypertension and left atrial enlargement. (Iranian Heart Journal 2026; 27(4): 16-24)

https://journal.iha.org.ir/article_254162_f080e6ebcf652aee713a9c0002aa42c7.pdf

Iranian Heart Association Iranian Heart Journal 27 4 2026 10 01 Association Between Sacubitril/Valsartan and Health Care Use: A Single-Center Retrospective Study From Turkey 25 39 254163 EN Onur Osman Şeker Samsun Educatıon And Research Hospital, Department of Cardiology, Samsun, Turkey. Nihan Bahadır Ordu University Faculty of Medicine, Department of Cardiology, Ordu, Turkey. Seçkin Dereli Ordu University Faculty of Medicine, Department of Cardiology, Ordu, Turkey. 0000-0003-0090-3835 Journal Article 2025 07 10 Aim: This study aimed to evaluate changes in health care utilization associated with sacubitril/valsartan (S/V) treatment by comparing outpatient clinic visits, emergency unit admissions, and hospitalizations before and after S/V treatment. Methods: This retrospective study included 108 patients with heart failure with reduced ejection fraction (HFrEF) (mean [SD] age, 67 [20] years; 83% male; 70% ischemic etiology) who had been using S/V for at least 1 year and were followed at a tertiary hospital between December 2021 and January 2023. Patient data for outpatient visits, emergency unit admissions, and hospitalizations were retrieved from the e-Nabız application. Paired statistical analyses (paired-samples t test, Wilcoxon signed-rank test, and McNemar test) were performed to compare parameters before and after S/V initiation. Results: Significant reductions were observed in the mean annual numbers of outpatient clinic visits (5.10 [1.95] vs 3.05 [1.25]; P < .001) and emergency unit admissions (4.40 [1.10] vs 2.80 [0.85]; P < .001) after S/V initiation. Furthermore, there was a significant decrease in the mean annual number of hospitalizations (3.20 [0.90] vs 1.80 [0.60]; P < .001), length of each stay (6.9 [3.5] vs 3.6 [1.9] days; P < .001), intensive care unit (ICU) admission rate (41% vs 17%; P < .001), and ICU length of stay (3.1 [0.9] vs 1.7 [0.8] days; P < .001). Conclusions: S/V initiation was associated with significant reductions in outpatient clinic visits, emergency unit admissions, and hospitalizations, observed together with clinical and functional improvements in real-life patients with advanced HFrEF. These findings may assist cardiologists in countries where S/V is not reimbursed in deciding on its use. (Iranian Heart Journal 2026; 27(4): 25-39)

https://journal.iha.org.ir/article_254163_4ae94c70f611a7316606ba3e03f84285.pdf

Iranian Heart Association Iranian Heart Journal 27 4 2026 10 01 The Utility of the Lorenz Plot in Assessing Electrocardiographic Waveforms in Type 2 Diabetes with Sinus Rhythm: A Preliminary Controlled Clinical Observation 40 49 254164 EN Marwan Salih Al-Nimer College of Medicine, University of Diyala, 32001 Baqubah, Iraq. 0000-0002-5336-3353 Maryam Mohan Dawood Department of Ultrasound and Radiology, Ishtar Institute of Medical Technology, 10016 Baghdad, Iraq. 0009-0008-0973-4023 Journal Article 2025 07 25 Background: Analysis of the Lorenz plot (LP) has been studied in tachyarrhythmias resulting from many causes. Patients with diabetes have abnormal electrocardiographic (ECG) findings related to prolonged QT intervals and ventricular repolarization, which are causes of ventricular arrhythmias. This preliminary controlled observational clinical study aimed to demonstrate the shape and pattern of LP analysis in patients with diabetes with normal sinus rhythm. Methods: A total of 100 participants (42 healthy individuals and 58 patients with diabetes) were recruited from 2 diabetes centers in 2025. Characteristics of the participants and ECG records were obtained. Each record was analyzed by determining measurements related to different intervals and the LP up to 9 R-R(n) intervals. Results: Significantly shorter R-R(n) intervals, QRS dispersion, and TQ intervals, and significantly prolonged P-R intervals, QRS duration, and QT and JT intervals were observed in patients with diabetes compared with healthy participants. The LP analysis revealed that the patterns and morphologies were comet and comet-club (in healthy participants) and torpedo and cigarette (in patients with diabetes), respectively. A significant positive correlation between the Tp-e/QTc value and R-R(n)+1 was observed. Conclusions: Patients with diabetes have a distinct pattern and shape of the LP compared with healthy participants, and the R-R(n)+1 interval was significantly positively correlated with the Tp-e/QTc ratio. (Iranian Heart Journal 2026; 27(4): 40-49)

https://journal.iha.org.ir/article_254164_2859d1f8e31a76afd5d35cb089e674a6.pdf

Iranian Heart Association Iranian Heart Journal 27 4 2026 10 01 Bariatric Surgery Favorably Modulates Global Longitudinal Strain and Homeostatic Model Assessment for Insulin Resistance in Patients With Obesity Without Comorbidities 50 59 254167 EN Shokoufeh Hajsadeghi Research Center for Prevention of Cardiovascular Disease, Institute of Endocrinology & Metabolism, Iran University of Medical Sciences (IUMS), Tehran, IR Iran. Aida Iranpour Hematology and Oncology Department, Iran University of Medical Sciences, Tehran, IR Iran. Shiva Rahimipour Anaraki Faculty of Medicine, Iran University of Medical Sciences, Tehran, IR Iran. Alireza Majd Pouya Faculty of Medicine, Iran University of Medical Sciences, Tehran, IR Iran. Elahe Saberi Shahrbabaki Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran. Ali Saberi Shahrbabaki Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran. Journal Article 2025 09 16 Background: The present study assessed the effect of bariatric surgery (BS) on left ventricular global longitudinal strain (LV-GLS) and homeostatic model assessment for insulin resistance (HOMA-IR) and investigated whether a correlation exists between LV-GLS and HOMA-IR in obese patients without comorbidities. Methods: Patients with a body mass index (BMI) above 35 were included and underwent varying BS procedures. Patients’ data, comprising BMI calculation, HOMA-IR with fasting glucose and fasting insulin measurements, and evaluation of GLS with tissue Doppler echocardiography, were collected before BS and at 12-month follow-up after BS. Results: A total of 142 patients who underwent BS were included in the study. BS significantly reduced HOMA-IR (mean difference, 3.79; P < .001), and mean GLS improved substantially postoperatively (mean difference, −3.25; P < .001). Among 18 patients with either borderline or abnormal GLS, all experienced improvement of GLS to the normal range in post-surgery follow-up (mean difference, −6.3; P < .01). Changes in GLS and HOMA-IR did not show a significant correlation with one another. Improvement in GLS and HOMA-IR scores did not differ significantly between BS subtypes (P = .78 and .83, respectively). Conclusions: GLS could be measured before and after BS to determine LV function improvement in obese patients, given that obesity may have a direct hemodynamic effect on LV function independent of other consequences, such as hypertension and diabetes. Furthermore, regardless of the BS technique used, BS has a positive impact on HOMA-IR and GLS. (Iranian Heart Journal 2026; 27(4): 50-59)

https://journal.iha.org.ir/article_254167_e69030d135b9a81859e2fe51dd968287.pdf

Iranian Heart Association Iranian Heart Journal 27 4 2026 10 01 Incidence of Total Occlusion of Major Coronary Arteries Without ST-T Wave Changes in Patients With Acute Coronary Syndrome 60 72 254168 EN Mahmoud Abdelkhalekh Abouomar Cardiology Department, Tanta Faculty of Medicine Tanta University, Egypt. 0000-0002-6105-9300 Ahmed Faruok Alaarag Cardiology Department, Tanta Faculty of Medicine Tanta University, Egypt. 0000-0002-6596-4834 Ahmed Ahmed Elheet Department of Cardiac Science, Al Hada Armed Forces Hospitals, West Region, Taif, Saudi Arabia. 0000-0002-1476-8948 Ayman Ahmed Elshikh Cardiology Department, Tanta Faculty of Medicine Tanta University, Egypt. 0000-0001-6956-2034 Hazem K Shalaby Cardiology Department, Tanta Faculty of Medicine Tanta University, Egypt. 0000-0001-7859-170X Journal Article 2025 11 28 Background: Acute coronary occlusion may occur without diagnostic ST-segment elevation. This study examined the incidence and angiographic patterns of total coronary occlusion and the impact of reperfusion timing on outcomes. Methods: In this retrospective observational study, 300 participants with acute coronary syndrome (ACS) who presented between July 2023 and July 2024 were included. Based on admission electrocardiography (ECG), participants were categorized into 3 groups: STEMI (n = 103), ST-segment depression and/or T-wave abnormalities (n = 125), and normal ECG (n = 72). Clinical characteristics, serial cardiac biomarkers, echocardiographic findings, coronary angiographic data, door-to-balloon (DTB) time, and clinical outcomes were analyzed. Results: Baseline characteristics were similar across groups, except for older age in participants with ST-segment depression/T-wave abnormalities (P < .001). High-sensitivity troponin elevation was common in participants with ischemic ECG changes but less frequent in those with normal ECGs (P = .001). Participants with ST-segment elevation myocardial infarction (STEMI) had more regional wall motion abnormalities and lower left ventricular ejection fraction (P = .001). Proximal left anterior descending and right coronary artery occlusions predominated in participants with ischemic ECG changes, whereas left circumflex (LCX) and obtuse marginal occlusions were more frequent in those with normal ECGs (P = .03). DTB times less than 90 minutes were achieved in 89.3%, 83.2%, and 62.5% of STEMI, ST-segment depression, and normal ECG groups, respectively (P = .001). In participants with total LCX occlusion, a DTB time less than 90 minutes was associated with lower mortality and shorter hospital stay. Conclusions: Participants with ACS may have complete coronary occlusion despite absence of diagnostic ST-segment elevation, particularly with LCX involvement. Reliance on ECG findings alone may delay recognition and reperfusion. Serial cardiac biomarkers, echocardiography, and early invasive assessment can improve diagnostic accuracy and facilitate timely management. (Iranian Heart Journal 2026; 27(4): 60-72)

https://journal.iha.org.ir/article_254168_1a6bb5b9bd488494e971a09ff292b991.pdf

Iranian Heart Association Iranian Heart Journal 27 4 2026 10 01 Serum Magnesium Level and Severity of Coronary Artery Disease 73 79 254169 EN Mohammad Erfani Department of Cardiology, School of Medicine Birjand University of Medical Sciences, Birjand, IR Iran. Mansour Moazzenzadeh Cardiovascular Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, IR Iran. 0000-0002-4391-8503 Hamidreza Rashidinejad Cardiovascular Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, IR Iran. Journal Article 2026 05 17 Objectives: In the present study, we aimed to investigate the relationship between serum magnesium level and the severity of coronary artery disease (CAD) and to determine whether lower magnesium levels are associated with more advanced coronary artery stenosis based on angiography and SYNTAX scoring. Methods: This cross-sectional study involved 203 patients who underwent elective coronary angiography at Shafa Hospital in Kerman, Iran, between 2023 and 2024. An initial stratification divided the patients into 2 groups based on angiographic evidence: normal angiography and coronary artery occlusion. The patients with blockages were further divided into nonsevere and severe CAD groups using the SYNTAX score. Serum magnesium level was measured before angiography. Researchers also recorded demographic and clinical data. Serum magnesium levels were assessed for normality using the Kolmogorov-Smirnov test, and the Kruskal-Wallis test was used for group comparisons. Results: The mean serum magnesium level was 2.52 (SD, 0.21) mg/dL in the normal group, 2.34 (SD, 0.27) mg/dL in the nonsevere CAD group, and 1.89 (SD, 0.25) mg/dL in the severe CAD group. There was a strong inverse relationship between magnesium levels and CAD severity (P < .001). Conclusions: Lower serum magnesium levels were significantly associated with greater severity of CAD. These findings highlight a potential association between serum magnesium status and the extent of CAD. Still, further prospective studies are needed to clarify the clinical significance of this relationship. (Iranian Heart Journal 2026; 27(4): 73-79)

https://journal.iha.org.ir/article_254169_6633a68ced7d429e450a0672e6331c28.pdf

Iranian Heart Association Iranian Heart Journal 27 4 2026 10 01 Primary Cardiac Angiosarcoma With Pulmonary Metastasis in A Young Female: A Case Report 80 86 254171 EN Nastaran Kordjazy Department of Anesthesiology and Critical Care, School of Medicine, Golestan University of Medical Sciences, Gorgan, IR Iran. 0000-0002-1476-0882 Roya Parkhideh Department of Cardiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, IR Iran. 0000-0001-9806-3293 Azadeh Sadatnaseri Department of Cardiology, Sina Hospital, Tehran University of Medical Sciences, Tehran, IR Iran. Morteza Foroumandi Department of Critical Care Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, IR Iran. Piroozeh Taheri Cardiovascular Research Center, Rajaei Cardiovascular Institute, Tehran, Iran. 0009-0000-8817-3077 Journal Article 2025 10 06 Cardiac angiosarcoma is a rare and highly aggressive malignancy with nonspecific clinical manifestations, often leading to delayed diagnosis. In this article, we report a 38-year-old woman who presented with diarrhea, dry cough, and a history of blunt chest trauma 3 weeks prior to admission. Initial echocardiography revealed massive pericardial effusion complicated by cardiac tamponade. Further diagnostic evaluation, including cardiac computed tomographic angiography, demonstrated right atrial wall rupture. Intraoperative sampling of the pulmonary nodules and the ruptured atrial wall was performed, and histopathologic examination confirmed metastatic cardiac angiosarcoma. Despite surgical intervention, and given the advanced stage of the tumor, the oncology team recommended palliative care. The patient developed progressive right-sided heart failure and died after a 53-day stay in the intensive care unit. This case highlights the diagnostic challenges of cardiac angiosarcoma and underscores the importance of early recognition and stage-appropriate management to improve clinical outcomes. (Iranian Heart Journal 2026; 27(4): 80-86)

https://journal.iha.org.ir/article_254171_deef4a5d28d1a9f1d4407c6735445e89.pdf

Iranian Heart Association Iranian Heart Journal 27 4 2026 10 01 Inferior ST-Segment Elevation in an Asymptomatic Young Patient With Left Anterior Descending Artery Myocardial Bridging: A Case Report 87 91 254174 EN Ahmed Elmi Abdi Department of Cardiology, Mogadishu Somali Turkish Training and Research Hospital, Mogadishu, Somalia. 0009-0006-4827-7393 Can Baba Arin Cardiology Department, Health Science University, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital Istanbul, Turkey. Mohamed Omar Hassan Department of Cardiology, Mogadishu Somali Turkish Training and Research Hospital, Mogadishu, Somalia. Journal Article 2025 07 14 Background: Myocardial bridging (MB) is a congenital coronary anomaly in which a segment of an epicardial coronary artery courses intramyocardially, resulting in dynamic systolic compression. MB, albeit usually considered benign, has been associated with myocardial ischemia and electrocardiographic abnormalities in selected patients. Nonetheless, establishing a causal relationship may be challenging. Case Presentation: A 33-year-old asymptomatic man with no prior cardiovascular disease was found to have inferior ST-segment elevation on routine electrocardiographic evaluation. Physical examination, transthoracic echocardiography, and laboratory findings were unremarkable. Coronary angiography demonstrated an MB involving the midsegment of the left anterior descending artery without evidence of obstructive coronary artery disease. The MB represented one potential explanation for the electrocardiographic findings; however, other mechanisms such as coronary vasomotor dysfunction could not be excluded because physiologic and vasoreactivity testing were not performed. Conclusions: This case illustrates an uncommon coexistence of inferior ST-segment elevation and an MB of the left anterior descending artery. Although a causal relationship cannot be established, MB should be considered among the differential diagnoses after exclusion of obstructive coronary artery disease. (Iranian Heart Journal 2026; 27(4): 91-95)

https://journal.iha.org.ir/article_254174_0de9e8be051c2719482ad1cf551048aa.pdf