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1.  Is there any relationship between different phenotypes of metabolic syndrome and cardiovascular mortality rate? 
Background:
This study aimed to focus on different phenotypes of metabolic syndrome (MetS) and their impact on the cardiovascular disease (CVD) events among a sample of the Iranian population.
Materials and Methods:
The Isfahan cohort study is a population-based, on-going longitudinal study of adults aged 35 years old or more, living in urban and rural areas of three counties in central Iran namely Isfahan, Najafabad and Arak. Participants were selected by multistage random sampling and were recruited to reflect the age, sex and urban/rural distribution of the community. The sample was restricted to subjects with MetS based on the National Cholesterol Education Program Adult Treatment Panel III criteria and no history of coronary heart disease, stroke, or cancer at the time of the baseline clinical examination.
Results:
Among different phenotypes of MetS components, clustering of high triglycerides (TGs), low high-density lipoprotein (HDL) and abdominal obesity (ABO) was the most related to the all-cause mortality among women and followed in order by high TGs, hypertension (HTN) and ABO. In men, the highest rate of all-cause mortality was related to high TGs, low HDL, and HTN. Clustering of four components (high TGs, low HDL and HTN and obesity) is the most related to all-cause mortality in the both sexes (12.1% in men, and 21.5% in women).
Conclusion:
This study showed different phenotypes of MetS related with all-cause mortality rate and existing HTN in the phenotype of MetS increased the incidence of CVD mortality.
doi:10.4103/2277-9175.192727
PMCID: PMC5156976  PMID: 28028525
All-cause mortality rate; Iran; metabolic; phenotype; syndrome
2.  The Effect of Nutrition Consultation on Dietary Diversity Score of Cardiac Patients Referred to Cardiac Rehabilitation Research Center Isfahan Cardiovascular Research Institute during 2008–2013 
Background:
Dietary diversity score (DDS) measurement was used to assessment of diet quality in different disease like cardiovascular disease. One way to improve the cardiovascular patient's ability is cardiac rehabilitation program that include exercise training, nutrition consultation and psychological treatment. No study was designed to compare the DDS before and after dietary consultation among cardiac rehabilitation patients, so this study was designed to examine this purpose.
Methods:
Subjects were participated in the 2-month cardiac rehabilitation program. All patients that completed the cardiac rehabilitation program and 2 dietary records (before and after nutritional counseling in cardiac rehabilitation program) enrolled in study. Kant et al method was used for scoring dietary diversity. Data were analyzed using the statistical package for social sciences (SPSS version 20). Wilcoxon test were used to compare DDS score for each subgroup and pair sample T test was used to compare total DDS after and before nutrition counseling. P < 0.05 was considered as statistically significant.
Results:
The differences between DDS of grain, fruit, vegetable and meat before and after nutrition counseling were not significant (P = 0.635, P = 0.423, P = 0.826, P = 0.207 respectively), but differences of DDS for dairy and total DDS before and after nutrition counseling were significant (P = 0, P = 0.001).
Conclusions:
Dietary diversity was increased after nutrition counseling among patients with cardiac disease.
doi:10.4103/2008-7802.193464
PMCID: PMC5139448  PMID: 27994822
Cardiac rehabilitation; dietary diversity score; nutrition consultation
3.  The difference in correlation between insulin resistance index and chronic inflammation in type 2 diabetes with and without metabolic syndrome 
Background:
Insulin resistance (IR) is associated with low-grade systemic inflammation. It plays an important role in the pathogenesis of type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD) in patients with metabolic syndrome (MetS). It is unclear whether diabetic patients with MetS confer elevated CVD risk and outcomes beyond the impact of individual's components of MetS. The aim of this study is to highlight the central role of IR, inflammation, triglyceride/high-density lipoprotein- cholesterol (TG/HDL-C) ratio, and atherogenic index of plasma (AIP) in T2DM with MetS.
Materials and Methods:
This cross-sectional study comprised 130 men distributed into three groups, namely Controls: 40 nondiabetic healthy volunteers; Group I: 40 T2DM patients without MetS, and Group II: 50 T2DM patients with MetS. Fasting blood samples were collected for the measurement of blood lipid profile, glucose, insulin, hemoglobin A1c, and high-sensitivity C-reactive protein (hs-CRP). TG/HDL-C ratio, AIP, and homeostasis model assessment of insulin resistance (HOMA-IR) were calculated.
Results:
Significant positive association was observed between HOMA-IR and hs-CRP only in Group II and between HOMA-IR and TG/HDL-C ratio in all subjects. Significant differences were seen in waist and hip circumferences, waist/hip ratio, body mass index, systolic blood pressure, fasting blood glucose, TGs, HDL-C, insulin, hs-CRP, HOMA-IR, TG/HDL ratio, and AIP between Controls and Group I with Group II.
Conclusions:
In T2DM with MetS, coexistence of elevated atherogenic indices, systemic inflammation, and association between HOMA-IR and TG/HDL-C ratio were seen. These factors are considered having important role in elevated CVD risk beyond MetS components in these patients.
doi:10.4103/2277-9175.188489
PMCID: PMC5046740  PMID: 27713874
Atherogenic index of plasma; inflammation; insulin resistance index; metabolic syndrome; triglyceride/high-density lipoprotein -cholesterol ratio; type 2 diabetes mellitus
4.  Association between serum myeloperoxidase levels and coronary artery disease in patients without diabetes, hypertension, obesity, and hyperlipidemia 
Background:
Myeloperoxidase (MPO) is an enzyme, elevated in the atheroma and serum of a patient with atherosclerotic vessels. The aim of this study is to investigate whether the serum MPO level is related to the presence of plaque in patients without risk factors, such as, diabetes, hypertension, obesity, and hyperlipidemia.
Materials and Methods:
A serum sample was collected from patients who referred for angiography. The MPO level was measured in the serum samples of 40 patients without risk factors for atherosclerosis using the enzyme-linked immunosorbent assay (ELISA).
Results:
The MPO level was 245.5 ± 13.8 (ng/ml) in patients with atherosclerosis and 213.9 ± 8.9 (ng/ml) in patients without atherosclerosis. There was a significant difference between the groups (P = 0.002). The odds ratio was 0.67 (0.95 CI, 0.17 – 2.5) for patients with and without coronary atherosclerosis.
Conclusion:
Although the MPO concentration is higher in patients suffering from atherosclerosis, it is not a predictor of coronary artery disease in patients without diabetes, hypertension, obesity, and hyperlipidemia.
doi:10.4103/2277-9175.183663
PMCID: PMC4918211  PMID: 27376042
Acute coronary syndrome; coronary artery disease; myeloperoxidase
5.  Comparison of health-related quality of life after percutaneous coronary intervention and coronary artery bypass surgery 
ARYA Atherosclerosis  2016;12(3):124-131.
BACKGROUND
Health-related quality of life (HRQOL) evaluation is an important measure of the impact of the disease. As more people with coronary heart disease (CHD) live longer, doctors and researchers want to know how they manage in day to day life. It looked like adults with CHD had a decrease QOL. The aim of this study was to comparison of HRQOL of patients who underwent percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) and to assess its main determinants in the whole sample of coronary artery disease (CAD) patients.
METHODS
The study was carried out to estimate HRQOL of 109 patients who underwent invasive coronary revascularization [PCI (n = 75) and CABG (n = 34)]. We applied HRQOL after 6 months and 2 years in both groups and scores were compared. The HRQOL data were obtained using MacNew Heart Disease questionnaire with dimensions emotional, physical and social that estimated. Data entry and analysis were performed by SPSS.
RESULTS
A total MacNew scale in CABG and PCI group in 6 months after treatment were 45.32 ± 13.75 and 53.52 ± 15.63, respectively (P = 0.010). After 2 years HRQOL mean changed to 51.176 ± 14.80 and 49.55 ± 16.22, respectively, in CABG and PCI group (P = 0.428). Our results in within-group analysis showed total MacNew scale and its subscales were changed significantly after 2 years in CABG and PCI group’s scores were detected. We found in the whole sample of CAD patients those who had a higher level of income and education and were not either overweight or obese experienced better HRQOL.
CONCLUSION
Our results showed that patients who underwent PCI experienced significantly higher HRQOL in 6 months after revascularization but over 24 months follow-up no difference was observed between the two groups.
PMCID: PMC5055370  PMID: 27752269
Quality of Life; Percutaneous Coronary Intervention; Coronary Artery Bypass Graft; MacNew Scale; Iran
6.  Predictive role of adiponectin and high-sensitivity C-reactive protein for prediction of cardiovascular event in an Iranian cohort Study: The Isfahan Cohort Study 
ARYA Atherosclerosis  2016;12(3):132-137.
BACKGROUND
Numerous studies have been conducted on the predictive effects of high-sensitivity C-reactive protein (hs-CRP) on cardiovascular events. Few studies have been conducted to investigate the effects of adiponectin for the prediction of the incident of cardiovascular events in the Middle East area. This study compared the predictive effect of hs-CRP and adiponectin on healthy volunteers for the prediction of cerebrovascular disease (CVD).
METHODS
This nested case-control in original Isfahan Cohort Study (ICS) was conducted from 2001 to 2011. Participants were selected from ICS. The case group included participants with CVD while the control group included participants without CVD. The level of hs-CRP and adiponectin was measured in the blood samples collected in the year 2007. Thereafter, the statistical analyses were performed to determine the predictive value of hs-CRP and adiponectin in CVD prediction.
RESULTS
The results showed that before the elimination of diabetes effect; there was a significant difference between the two groups, in terms of the mean of adiponectin (P = 0.019) and no significant difference was observed in hs-CRP levels (P = 0.673). However, after eliminating the factor of diabetes, there was no significant difference between the case and control groups in adiponectin and hs-CRP levels (P = 0.184, P = 0.946). The results showed that the odds ratio (OR) of the adiponectin level was 0.879 [95% confidence interval (CI): 0.719-1.075, P = 0.210] while the OR of hs-CRP was 1.045 (95% CI: 0.922-1.185, P = 0.491). Furthermore, it was shown that after adjustment for age, sex, and diabetes; the OR of adiponectine was 0.875 (95% CI: 0.701-1.091, P = 0.235) and that of hs-CRP was 1.068 (95% CI: 0.935-1.219, P = 0.333).
CONCLUSION
The results show that adiponectin and hs-CRP cannot be predictors for cardiovascular events in a healthy population. Risk factors such as diabetes limit the use of adiponectin as a CVD predictor.
PMCID: PMC5055371  PMID: 27752270
Adiponectin; High-Sensitivity C-Reactive Protein; Cardiovascular Disease
7.  Predicting metabolic syndrome using decision tree and support vector machine methods 
ARYA Atherosclerosis  2016;12(3):146-152.
BACKGROUND
Metabolic syndrome which underlies the increased prevalence of cardiovascular disease and Type 2 diabetes is considered as a group of metabolic abnormalities including central obesity, hypertriglyceridemia, glucose intolerance, hypertension, and dyslipidemia. Recently, artificial intelligence based health-care systems are highly regarded because of its success in diagnosis, prediction, and choice of treatment. This study employs machine learning technics for predict the metabolic syndrome.
METHODS
This study aims to employ decision tree and support vector machine (SVM) to predict the 7-year incidence of metabolic syndrome. This research is a practical one in which data from 2107 participants of Isfahan Cohort Study has been utilized. The subjects without metabolic syndrome according to the ATPIII criteria were selected. The features that have been used in this data set include: gender, age, weight, body mass index, waist circumference, waist-to-hip ratio, hip circumference, physical activity, smoking, hypertension, antihypertensive medication use, systolic blood pressure (BP), diastolic BP, fasting blood sugar, 2-hour blood glucose, triglycerides (TGs), total cholesterol, low-density lipoprotein, high density lipoprotein-cholesterol, mean corpuscular volume, and mean corpuscular hemoglobin. Metabolic syndrome was diagnosed based on ATPIII criteria and two methods of decision tree and SVM were selected to predict the metabolic syndrome. The criteria of sensitivity, specificity and accuracy were used for validation.
RESULTS
SVM and decision tree methods were examined according to the criteria of sensitivity, specificity and accuracy. Sensitivity, specificity and accuracy were 0.774 (0.758), 0.74 (0.72) and 0.757 (0.739) in SVM (decision tree) method.
CONCLUSION
The results show that SVM method sensitivity, specificity and accuracy is more efficient than decision tree. The results of decision tree method show that the TG is the most important feature in predicting metabolic syndrome. According to this study, in cases where only the final result of the decision is regarded significant, SVM method can be used with acceptable accuracy in decision making medical issues. This method has not been implemented in the previous research.
PMCID: PMC5055373  PMID: 27752272
Machine Learning; Metabolic Syndrome; Decision Tree; Support Vector Machine
8.  Effect of cardiac rehabilitation on metabolic syndrome and its components: A systematic review and meta-analysis 
Background:
Although the effect of cardiac rehabilitation (CR) on cardiovascular disease (CVD) prognosis has been well-documented by several systematic reviews, none have focused on the effect of CR on metabolic syndrome (MetS) and its related components. Therefore, the present systematic review and meta-analysis was conducted to assess the effect of CR on MetS and its components.
Materials and Methods:
PubMed, SCOPUS, Cochrane library, and Google Scholar database were searched up to February 2014 with no date and language restrictions. The random effects model was used to assess the overall effect of CR on MetS prevalence and the change in metabolic or anthropometric measures.
Results:
Fifteen studies with 19,324 subjects were included in the present systematic review and meta-analysis. Our analysis showed that the CR could significantly reduce MetS prevalence [reduction rate: 0.25, 95% confidence interval (CI): 0.21, 0.3, P value <0.001; P value for heterogeneity <0.001, I-squared: 86.2%]. Additionally, results showed the protective role of CR on all MetS components including high density lipoprotein cholesterol [mean difference (MD): 2.13 mg/dL, 95% CI: 1.17, 3.1], triglyceride (MD: -27.45 mg/dL, 95% CI: −36.92, −17.98), systolic blood pressure (SBP) (MD: −6.20 mmHg, 95% CI: -8.41, −3.99), diastolic blood pressure (DBP) (MD: −2.53 mmHg, 95% CI: −3.64, −1.41), fasting blood sugar (FBS) (MD: −6.42 mg/dL, 95% CI: −6.85, −5.99), and waist circumference (WC) (MD: −2.25 cm, 95% CI: −3.15, −1.35).
Conclusion:
CR has resulted in improvement in MetS and its entire components, and could be considered as a useful tool for MetS patients, especially among those with CVD.
doi:10.4103/1735-1995.178757
PMCID: PMC5122180  PMID: 27904564
Cardiac rehabilitation (CR); meta-analysis; metabolic factors; syndrome x
9.  Predictive factors of short-term survival from acute myocardial infarction in early and late patients in Isfahan and Najafabad, Iran 
ARYA Atherosclerosis  2016;12(2):59-67.
BACKGROUND
Cardiovascular disease (CVD) is the primary cause of mortality in the world and Iran. The aim of this study was to determine the prognostic factors of short-term survival from acute myocardial infarction (AMI) in early and late patients in the Najafabad and Isfahan County, Iran.
METHODS
This hospital-based cohort study was conducted using the hospital registry of 1999-2009 in Iran. All patients (n = 14426) with an AMI referred to hospitals of Isfahan and Najafabad were investigated. To determine prognostic factors of short-term (28-days) survival in early and late patients, unadjusted and adjusted hazard ratio (HR) was calculated using univariate and multivariate Cox regression.
RESULTS
The short-term (28-day) survival rate of early and late patients was 96.64% and 89.42% (P < 0.001), respectively. In 80% of early and 79.3% of late patients, mortality occurred during the first 7 days of disease occurrence. HR of death was higher in women in the two groups; it was 1.97 in early patients was (CI95%: 1.32-2.92) and 1.35 in late patients (CI95%: 1.19-1.53) compared to men. HR of death had a rising trend with the increasing of age in the two groups.
CONCLUSION
Short-term survival rate was higher in early patients than in late patients. In addition, case fatality rate (CFR) of AMI in women was higher than in men. In both groups, sex, age, an atomic location of myocardial infarction based on the International Classification of Disease, Revision 10 (ICD10), cardiac enzymes, and clinical symptoms were significant predictors of survival in early and late patients following AMI.
PMCID: PMC4933744  PMID: 27429625
Myocardial Infarction; Survival Rate; Early; Late; Regression Analysis; Iran
10.  Do Cardiometabolic Risk Factors Relative Risks Differ for the Occurrence of Ischemic Heart Disease and Stroke? 
Background:
The effects of the risk factors of ischemic heart disease (IHD) and stroke on the occurrence of these diseases differ between different populations.
Objectives:
To study the difference in the effects of different cardiovascular (CVD) risk factors on the incidence of IHD and stroke in an Iranian adult population.
Patients and Methods:
The Isfahan Cohort Study (ICS) is a longitudinal study that followed up 6323 subjects older than 35 years with no history of CVD since 2001. Of the original sample, only 5431 participants were contacted and followed up until 2011. The end points were the occurrence of IHD (defined as fatal and non-fatal myocardial infarction, unstable angina, and sudden cardiac death) and stroke. After 10 years of follow-up, 564 new cases of IHD and 141 new cases of stroke were detected. The relative risks (RRs) of cardiometabolic risk factors such as hypertension, diabetes, hypercholesterolemia, hypertriglyceridemia, high low-density lipoprotein cholesterol (LDL-C) level, low high-density lipoprotein cholesterol (HDL-C) level, current smoking, obesity, high waist-to-hip ratio, family history of CVD, and metabolic syndrome were compared between IHD and stroke patients. The ratio of relative risks (RRR) was calculated for comparing two RRs and estimated adjusted RRR was calculated by using generalized linear regression with a log link and binomial distribution.
Results:
The RRs of the occurrence of IHD and stroke in diabetic patients were 1.94 and 3.26, respectively, and the difference was statistically different (P = 0.016). The RR of high LDL-C was significantly higher for IHD than for stroke (P = 0.045), while all the other risk factors showed similar RRs for IHD and stroke, with no significant difference in their RRR, including hypertension. Diabetes and hypertension had the highest RRs for IHD, followed by diabetes, metabolic syndrome, and hypertension for stroke.
Conclusions:
The effect of diabetes mellitus on stroke was more significant than on IHD, and the effect of high LDL-C level was more significant on IHD than on stroke, other risk factors, including hypertension, have similar RRs for IHD and stroke. Health care professionals need more training regarding the RRs of these risk factors in the Iranian society, and health decision makers should consider it in their future policies.
doi:10.5812/cardiovascmed.30619
PMCID: PMC4752672  PMID: 26889461
Cardiovascular Diseases; Risk Factors; Stroke; Myocardial Ischemia; Cohort Studies
11.  Effects of hope promoting interventions based on religious beliefs on quality of life of patients with congestive heart failure and their families 
Background:
Heart failure is one of the most important and prevalent diseases that may have negative effects on the quality of life (QOL). Today, the promotion of QOL in patients with heart failure is important in nursing care programs. This research aimed to determine the efficacy of hope-promoting interventions based on religious beliefs on the QOL of patients with congestive heart failure (CHF).
Materials and Methods:
In this randomized clinical trial (IRCT2014100619413N1) conducted in Isfahan, Iran, 46 adult patients with CHF were selected and randomly assigned to study and control groups. Ferrans and Powers Quality of Life Index (QLI) was completed by both groups before, immediately after, and 1 month after the intervention. For the study group participants and their families, 60-min sessions of hope-promoting interventions based on religious beliefs were held twice a week for 3 weeks. Independent t, repeated measures analysis of variance (ANOVA), Chi-square, Mann–Whitney, and Fisher's exact tests were adopted for data analysis.
Results:
The mean (standard deviation) overall QOL score in the area of satisfaction significantly increased in the study group, compared to the controls, immediately [70.7 (8.5) vs. 59.2 (12.5)] and 1 month after the intervention [75.2 (7.4) vs. 59.4 (12.9)] (P < 0.05). There was also a similar difference between the two groups in the area of importance immediately [73.6 (5.8) vs. 65.7 (7.5)] and 1 month after the intervention [76.3 (8.1) vs. 66.8 (8.5)] (P < 0.05).
Conclusions:
Hope-promoting intervention based on religious beliefs is a useful method for improving QOL in patients with CHF.
doi:10.4103/1735-9066.174755
PMCID: PMC4776564  PMID: 26985226
Congestive heart failure; hope promoting; Iran; quality of life; religious beliefs
12.  Does the impact of metabolic syndrome on cardiovascular events vary by using different definitions? 
BMC Public Health  2015;15:1313.
Background
Metabolic Syndrome (MetS) is a complex disorder which increases the risk of chronic diseases, including cardiovascular diseases and diabetes mellitus. As a result of modern lifestyles, the prevalence of MetS has been rising globally. This study aims to investigate whether overall prevalence of MetS varies when using different definitions of MetS and to identify the best and most predictive definition of the MetS for cardiovascular disease (CVD) events over 10 years in a cohort of an Iranian population.
Method
Adults aged ≥ 35 years from urban and rural regions in central Iran were selected at baseline and followed up for more than 10 years. Data on socio-demographic characteristics, anthropometry, blood pressure and smoking status were collected at baseline. In addition, various biochemical indices were assessed. MetS was defined based on five available definitions, and cardiovascular events during 10 years follow up were confirmed by an expert group. The hazard ratios were calculated by the Cox proportional hazards model.
Results
The highest prevalence of MetS was observed by using AHA-NHBI definition (36.9 %), followed by JIS definition (31.2 %). On the other hand, EGIR (8.8 %) provided the lowest prevalence. The risk of developing CVD, irrespective of definitions, was approximately two fold higher in the presence of MetS. After controlling for possible confounders, AHA-NHBI definition was found to be the best predictor of CVD.
Conclusion
This study demonstrated a great variability in the prevalence of MetS among Iranian adults when using different definitions of MetS. CVD risk was significantly higher in MetS participants, as well as in participants with any risk factors of MetS; however, the AHA-NHBI definition was found to be the best predictor of CVD. Thus protective measures, including lifestyle modifications, plus control of individual risk factors is necessary to prevent cardiovascular events.
doi:10.1186/s12889-015-2623-3
PMCID: PMC4696331  PMID: 26715355
Metabolic syndrome; Obesity; Diabetes; Hypertension; Cardiovascular diseases
13.  Prognostic factors of 28 days survival rate in patients with a first acute myocardial infarction based on gender in Isfahan, Iran (2000-2009) 
ARYA Atherosclerosis  2015;11(6):332-340.
BACKGROUND
Determinant prognostic factors of 28 days survival rate in patients with a first acute myocardial infarction (AMI) based on gender in teen year’s period in Isfahan, Iran, was the aim of this study.
METHODS
This study is a prospective hospital-based study that consisted, all patients with AMI admitted to all hospitals (private and universal hospitals) in Isfahan and Najafabad (Iran) during 2000-2009. To determinant the prognostic factors of 28 days survival rate in patients based on gender, analysis conducted separately for male and female. In analysis, we use of t-test, log Rank tests, Kaplan-Meier method, and univariate and multivariate Cox regression model.
RESULTS
Short-term (28 days) survival rate was 92.5% in male and 86.7% in female (P < 0.001). The adjusted hazard ratio (HR) of death for age group 80 years and older was 12.7 [95% confidence interval (CI): 5.14-31.3] in male and 8.78 (95% CI: 1.2-63.1) in female. HR for acute transmural MI of the unspecified site in male was 8.9 (95% CI: 4.68-16.97) and in female 9.33 (95% CI: 4.42-19.7). HR for receive of streptokinase in male was 1.11 (95% CI: 0.94-1.31) and in female was 0.69 (95% CI: 0.56-0.84).
CONCLUSION
Short-term survival rate in male was a higher than female. In male age, anatomic location of MI and hospital status and in female streptokinase use and anatomic location of MI was the most important prognostic factors of survival in-patient with AMI in Isfahan.
PMCID: PMC4738043  PMID: 26862341
Myocardial Infarction; Survival Rate; Gender; Isfahan (Iran)
14.  Better view on attitudes and perceived parental reactions behind waterpipe smoking among Iranian students 
Background:
Because of the increasing usage of waterpipe globally, we need to know more about the different factors related to waterpipe and cigarette smoking. Therefore, the present study aims at gaining more insight on waterpipe and cigarette smoking based on perceived parental reaction and appeal and repellent of smoking among adolescents.
Materials and Methods:
A cross-sectional survey entitled “Isfahan Tobacco Use Prevention Program” (ITUPP) was conducted among 5,500 adolescents in Isfahan Province, Iran in 2010 using a self-administered anonymous questionnaire. Demographic factors, cigarette and waterpipe smoking status, appeal and repellent of smoking, perceived parental reactions, and the main reasons behind the increase in waterpipe smoking were measured. Chi-square, univariate logistic regression, and multiple logistic regression were used. For all analyses, we defined statistical significance a priori with a two-tailed alpha of 0.05. Statistical analyses were conducted using the Statistical Package for the Social Sciences (SPSS) version 15.
Results:
50% of the sample was female and 89% lived in urban areas. The average age of the respondents was 14.37 ± 1. 70 years. While a majority of cigarette smokers (70.9%) were waterpipe smokers, only 35.7% of waterpipe smokers smoked cigarettes. The incidence of smoking was high in those who expected less extensive parental reaction with odds ratio (OR) = 1.89 [95% confidence interval (CI): 1.35-2.63] (P < 0.001) among cigarette smokers and OR = 2.75 (95% CI: 2.16-3.50) (P < 0.001) among waterpipe smokers. “Taste” was rated the most attractive feature by waterpipe and cigarette smokers 2.83-fold (95% CI: 2.06, 3.90) (P < 0.001). Most waterpipe smokers compared to nonsmokers believed that the main reason behind waterpipe popularity was habit.
Conclusion:
The factors related to waterpipe smoking were different from those in cigarette smoking; so we need to implement different interventions to overcome the surging usage of tobacco use.
doi:10.4103/1735-1995.172812
PMCID: PMC4755088  PMID: 26941805
Adolescents; attitude; Eastern Mediterranean Region (EMR); hookah; parent reaction; parents; perception; smoking; students; waterpipe
15.  Investigation of relationship between social capital and quality of life in female headed families 
Background: Although most studies on female-headed families focus on women's access to social support, the associations between social capital and quality of life in these families are unclear in many societies (such as Iran). This study aimed to determine the associations between social capital and quality of life in Iranian female headed families.
Methods: This cross-sectional study was performed on 152 female-headed households supported by Tehran Municipality, district 9 from April 2011 to July 2012. Convenience sampling was employed. Data were collected using demographic questionnaire, the Iranian version of World Health Organization Quality of Life, and the Word Bank Social Capital. Descriptive and multiple regression methods were used to analyze the data.
Results: The mean±SD age of participants was 50.8±13.8 years. Findings revealed that in quality of life, the domains of environment health and social relation received the lowest (9.87 ± 2.41) and the highest (12.61 ±3.43) scores respectively; and with respect to social capital, membership in groups and social trust had the least (19.61 ± 17.11) and the most (51.04 ± 17.37) scores, respectively. The multiple regression model revealed a significant positive association between total score of the quality of life and the total score for the social capital (p< 0.001).
Conclusion: Findings suggest that quality of life of female-headed families and social capital domains are strongly related. This means that by improving the social capital, women’s life can also be improved.
PMCID: PMC4715401  PMID: 26793661
Social Capital; Quality of life; Female-Headed Families (FHF)
16.  Effect of self-care education on lifestyle modification, medication adherence and blood pressure in hypertensive adults: Randomized controlled clinical trial 
Background:
Self-care management has recently been suggested as an effective approach for secondary prevention of hypertension. This study was conducted to examine whether self-care behaviors could modulate blood pressure levels and also comparing the different training methods of self-care on patients’ adherence and controlling hypertension.
Materials and Methods:
This study was a prospective randomized controlled clinical trial, conducted on 180 hypertensive patients referring to four centers in Isfahan, Iran, between July and December 2013. Block randomization method were applied to divide eligible subjects into four equal groups, including group A in which the patients and their family were educated by cardiology resident about self-care behaviors through eight sessions, group B and group C were obtained self-care education through four pamphlets or eight short message services (SMS), respectively and group D were obtained only usual care of hypertension without any training about self-care management.
Results:
Increasing vegetable intake and frequency of subject who took antihypertensive medication regularly and the reduction in the frequency of subjects who consumed high salt were significantly more in group A than the others (P = 0.001, P < 0.001 and P < 0.001, respectively). The systolic and diastolic blood pressure had significantly more reduction in the group A than the other groups (−8.18 ± 18.3 and − 3.89 ± 4.1; P < 0.001, respectively).
Conclusions:
The self-care management education integration into the usual care along with using SMS and other educational materials may improve the efficient and effective adherence strategies.
doi:10.4103/2277-9175.166140
PMCID: PMC4620611  PMID: 26601092
Blood pressure; hypertension; pamphlet; randomized controlled clinical trial; self-care; short message service
17.  Obstructive sleep apnea, diagnosed by the Berlin questionnaire and association with coronary artery disease severity 
ARYA Atherosclerosis  2015;11(5):275-280.
BACKGROUND
Obstructive sleep apnea syndrome (OSAS) is a highly prevalent sleep-related disorder that is associated with increased risk of hypertension (HTN) and coronary heart disease. This study aimed to evaluate the correlation between the OSAS and coronary artery disease (CAD) severity.
METHODS
The cross-sectional study was conducted from September 2012 to December 2013. We enrolled 127 patients with chronic stable angina who were referred for coronary angiographic studies in Shahid Chamran and Nour Hospitals in Isfahan, Iran. The Berlin questionnaire (BQ) was used for estimate the probability of OSAS in patients as a low or high probability. Demographic characteristics and metabolic risk factors including diabetes mellitus, HTN, obesity, and smoking also were recorded. The severity of CAD was assessed and compared based on the Gensini score with Mann-Whitney U statistical test. Independent t-test for continuous variables and chi-square test for categorical variables were used.
RESULTS
Totally, 65.4% of subjects were considered as high and 34.6% as low probability for OSAS, which 81.1% of them had CAD. There was a significant difference between body mass index, systolic blood pressure, diastolic blood pressure, and ischemic heart disease drug consumption with OSAS probability (P < 0.0500). CAD was accompanied by OSAS significantly (P = 0.0260). The Gensini score was significantly higher in patients with high OSAS probability (100.4 ± 69.1 vs. 65.3 ± 68.9; P = 0.0030). OSAS also increase odds of CAD based on regression analysis (odds ratio, 95% confidence interval = 2.7).
CONCLUSION
This study indicates that more severe CAD is associated with high OSAS probability identified by BQ.
PMCID: PMC4680075  PMID: 26715932
Coronary Artery Disease; Obstructive Sleep Apnea Syndrome; Berlin Questionnaire
18.  Biochemical changes in blood of type 2 diabetes with and without metabolic syndrome and their association with metabolic syndrome components 
Background:
Multiple factors are involved in the development and progression of type 2 diabetes mellitus (DMII) to DMII with metabolic syndrome (MetS) and cardiovascular complications. To identify some of these factors, we aim to investigate the changes in erythrocyte membrane Na+/K+-ATPase activity, serum glucose, insulin, lipid profile, hemoglobin A1C (HbA1c), high-sensitivity C-reactive protein (hs-CRP), anthropometric measurements, and blood pressure in DMII with and without MetS.
Materials and Methods:
This cross-sectional study comprised 155 male subjects distributed into three groups as healthy controls (50 non-DMII volunteers), Group I (50 DMII without MetS), and Group II (55 DMII with MetS). Fasting blood samples were taken for the measurement of glucose, insulin, HbA1c, hs-CRP and lipid profile. Na+/K+-ATPase activity was determined in erythrocyte ghost.
Results:
Na+/K+-ATPase activity was significantly decreased in DMII groups compared with controls. No significant difference was shown in Na+/K+-ATPase activity between DMII groups. Total ATPase activity, total cholesterol and low-density lipoprotein-cholesterol levels were similar in the three groups. Levels of insulin, hs-CRP, triacylglycerols, systolic blood pressure, weight, waist and hip circumference, waist/hip ratio, and body mass index were significantly elevated and high-density lipoprotein-cholesterol significantly decreased only in Group II. Significant differences in serum glucose and hip circumference were seen between the groups. No significant differences in HbA1c levels were observed between DMII groups.
Conclusion:
Changes in many of the measured risk factors that occurred only in Group II compared with controls and Group I may provide an explanation of how DMII progresses to DMII with MetS and future cardiovascular complications.
doi:10.4103/1735-1995.168383
PMCID: PMC4652310  PMID: 26664424
Lipid profile; metabolic syndrome; Na+/K+-ATPase activity; type 2 diabetes
19.  Development and validation of cardiac patient competence questionnaire, Iranian version 
ARYA Atherosclerosis  2015;11(4):220-227.
BACKGROUND
The aim was to translate and develop a patient competence (PC) questionnaire in the context of cardiology and test its validity and reliability.
METHODS
In total, 148 cardiac patients who have inclusion criteria of the study were completed cardiac PC (CPC) questionnaire. Hospital Anxiety and Depression Scale and self-administered instrument European quality of life 5-dimensions were used to further validate the CPC questionnaire. The CPC was translated according to the recommended methodology for translating questionnaires, and psychometric properties including internal consistency, factor analysis, discriminant validity, construct validity, and concurrent criterion validity were tested.
RESULTS
Five domains in problem-focused task including search for information, self-regulation, being assertive, independent decision-making, and looking for social services, and three domains in emotion-focused task including stress management, confronting the threat, and avoidance were obtained by factor analysis. The standardized Cronbach’s α of all domains were statistically significant (P < 0.001) and internal consistency for all domains was acceptable. Significant intercorrelations of CPC domains also indicated good criterion validity. As there were no cross-loadings, the domains have demonstrated good construct validity and discriminant validity.
CONCLUSION
The results of this study show that the Persian version of the CPC is a reliable and valid questionnaire. Although further improvement of this measure is clearly required, it suggests being a potential basis for investigating the determinants and health effects of CPC.
PMCID: PMC4593657  PMID: 26478729
Patient Competence; Cardiology; Reliability and Validity
20.  Trends of 28 days case fatality rate after first acute myocardial infarction in Isfahan, Iran, from 2000 to 2009 
ARYA Atherosclerosis  2015;11(4):233-243.
BACKGROUND
The purpose of the present study was the analysis of the trends in case fatality rate of acute myocardial infarction (AMI) in Isfahan, Iran. This analysis was performed based on gender, age groups, and type of AMI according to the International Classification of Diseases, version 10, during 2000-2009.
METHODS
Disregarding the Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA), this cohort study considered all AMI events registered between 2000 and 2009 in 13 hospitals in Isfahan. All patients were followed for 28 days. In order to assess the case fatality rate, the Kaplan-Meier analysis, and to compare survival rate, log-rank test were used. Using the Cox regression model, 28 days case fatality hazard ratio (HR) was calculated.
RESULTS
In total, 12,900 patients with first AMI were entered into the study. Among them, 9307 (72.10%) were men and 3593 (27.90%) women. The mean age in all patients increased from 61.36 ± 12.19 in 2000-2001 to 62.15 ± 12.74 in 2008-2009, (P = 0.0070); in women, from 65.38 ± 10.95 to 67.15 ± 11.72 (P = 0.0200), and in men, from 59.75 ± 12.29 to 59.84 ± 12.54 (P = 0.0170),. In addition, the 28 days case fatality rate in 2000-2009 had a steady descending trend. Thus, it decreased from 11.20% in 2000-2001 to 07.90% in 2008-2009; in men, from 09.20% to 06.70%, and in women, from 16.10% to 10.90%. During the study, HR of case fatality rate in 2000-2001 declined; therefore, in 2002-2003, it was 0.93 [95% confidence interval (CI) = 0.77-1.11], in 2004-2005, 0.88 (95% CI = 0.73-1.04), in 2006-2007, 0.67 (95% CI = 0.56-0.82), and in 2008-2009, 0.69 (95% CI = 0.56-0.82).
CONCLUSION
In Isfahan, a reduction was observable in the trend of case fatality rate in both genders and all age groups. Thus, there was a 29.46% reduction in case fatality rate (27.17% in men, 32.29% in women) during the study period.
PMCID: PMC4593659  PMID: 26478731
Case Fatality Rate; Myocardial Infarction; Trend; Iran
21.  The effect of resistance exercise on mean blood pressure in the patients referring to cardiovascular research centre 
Background:
One of the most important risk factors for cardiovascular disease is hypertension. 1 billion people in the world and 25–35% of the adult population in Iran suffer from hypertension. Despite the emphasis on medicational treatments, non-medicational treatments and modification of lifestyle, including physical activity and exercise, are important for the control and treatment of hypertension and lead to a reduction in cardiovascular diseases. Among the various types of exercises, resistance exercise has been considered important by the cardiologists. The present study investigates the effect of resistance exercise on mean blood pressure in the cardiovascular patients.
Materials and Methods:
In a randomized clinical trial, 40 patients admitted to the rehabilitation unit of cardiovascular research center were assigned to study and control groups. Demographic data were collected. Their blood pressure values were measured and recorded once 1 day before the beginning of the intervention and another time 1 day after its completion. All study subjects participated in two 45–60 min exercise sessions for eight straight weeks. The control group followed routine rehabilitation unit protocol that was aerobic exercise. The study group subjects performed resistance exercise in addition to routine exercise. The weight was determined in the first session of the intervention. At the beginning, the number of the repetitions in the range of motion was 10, which was increased gradually to 15. After it reached 15 repetitions, the amount of weight was increased by 3–5% and the number of sets increased.
Results:
One day before the beginning of the intervention, mean systolic blood pressure was 128.21 (15.39) mmHg in the study group and 120.00 (20.51) mmHg in the control group. Mean diastolic blood pressure was 82.50 (9.35) mmHg in the study group and 82.00 (13.11) mmHg in the control group. There were no differences between the groups in terms of mean systolic and diastolic blood pressure (P > 0.05). After the end of the intervention, mean systolic blood pressure values were 116.42 (7.18) mmHg and 112.00 (12.60) mmHg in the study and control groups, respectively. There were no significant differences between the groups (P = 0.24). Mean diastolic blood pressure values were 81.78 (7.99) mmHg in the study group and 78.25 (12.48) mmHg in the control group. There was no significant difference between the groups (P = 0.35). At the end of the intervention, mean systolic blood pressure in the study group decreased significantly (P = 0.02).
Conclusions:
In the present study, the effect of resistance exercise on mean systolic blood pressure showed a significant difference, caused by the aerobic exercise.
doi:10.4103/1735-9066.160999
PMCID: PMC4525339  PMID: 26257796
Blood pressure; coronary artery disease; resistance training
22.  Behavioral Change Challenges in the Context of Center-Based Cardiac Rehabilitation: A Qualitative Study 
Background:
Cardiovascular disease is chronic and often a sign of long-standing unhealthy lifestyle habits. Patients need support to reach lifestyle changes, well-being, join in social and vocational activity. Thus, patient responsibility should to be encouraged to provide quality as well as longevity. Cardiac rehabilitation programs aid patients in the attainment of these objectives. However, research shows that behavioral change following the diagnosis of a chronic disease is a challenge.
Objectives:
We sought to determine behavioral change challenges in patients with cardiovascular disease to improve intervention programs.
Patients and Methods:
Using a descriptive qualitative approach, we collected the data using 30 in-depth semi-structure interviews. Thematic analysis was conducted to identify themes from the data.
Results:
Three sources of behavioral change challenges emerged regarding the nature of cardiac disease and the role of the individual and the family in the recovery process. These challenges acted at two levels: intra- and interpersonal. The intrapersonal factors comprised value, knowledge and judgment about cardiovascular disease, and self-efficacy to fulfill the rehabilitation task. Family overprotection constituted the principal component of the interpersonal level.
Conclusions:
Behaviors are actually adopted and sustained by patients are so far from that recommended by health professionals. This gap could be reduced by identifying behavioral change challenges, rooted in the beliefs of the individual and the family. Therefore, culturally-based interventions to enhance disease self-management should be considered.
doi:10.5812/ircmj.17(5)2015.27504
PMCID: PMC4537786  PMID: 26290753
Behavior; Rehabilitation; Analysis
23.  Effect of age on the phenotype of metabolic syndrome in developing country 
Background:
This study aimed to determine how age groups effect on the phenotype of metabolic syndrome (MetS) among Iranian population.
Materials and Methods:
This cross-sectional study was conducted as part of Isfahan Healthy Heart Program. Height, weight, waist circumference, and blood pressure were measured by trained health-care professionals. MetS was defined as having three or more of the National Cholesterol Education Program III criteria. The relation between different age groups and different phenotypes of MetS was examined using the multinomial logistic regression.
Results:
We found low high-density lipoprotein-cholesterol (HDL-c) was the most common feature, followed by hypertriglyceridemia (HTG), abdominal obesity (ABO), hypertension (HTN), and high fasting blood glucose in decreasing order of prevalence. The most prevalent combination of MetS components was hypertrigeceridemia, low HDL-c and ABO (50.7%) in all subjects and especially in younger age group (63.2%). In elder age group, the most prevalent three components combination was HTG, Low HDL-c and HTN (43.9%). Logistic regression analysis demonstrated that elder subjects were at approximately 12 times higher risk of having the combination HTG, ABO, low HDL-c, and HTN (P < 0.001) compared to the middle age subjects who had a lower risk for the same combination; (2 [1.49-3.49]) (P < 0.001).
Conclusion:
This study provides a nationally representative estimate of the prevalence of different phenotypes of MetS across different age groups. Regarding different phenotypes of MetS in various age groups need to have important implications in the clinical management of these patients and the implementation of public health.
doi:10.4103/2277-9175.157796
PMCID: PMC4513307  PMID: 26261805
Age groups; Iran; metabolic cardiovascular syndrome; phenotype
24.  The metabolic syndrome and associated lifestyle factors among the Iranian population 
Background:
This study aims to evaluate the impact of the Isfahan Healthy Heart Program (IHHP) interventions concerning healthy behavior, on the prevalence of the metabolic syndrome (MetS) and its components in the Iranian population.
Materials and Methods:
The IHHP targeted the population at large in three districts in central Iran from 2000 to 2007. Numerous interventional activities were performed to improve lifestyle. The main intervention strategies were public education through mass media, intersectional cooperation, health professional education, marketing and organizational development, legislation and policy development, as well as research and evaluation. MetS was defined based on the Adult Treatment Panel (ATP) III definition. The logistic regression method was applied to explore the relationship between lifestyle factors with components of metabolic risk factors.
Results:
The mean age of the participants was 44.68 ± 14.43 years in 2001. The mean values of the MetS components differed from 2001 to 2007. The mean of systolic blood pressure (SBP) decreased from 126.7 ± 22.31 to 124.21 ± 20.0 and from 129.47 ± 23.08 to 126.26 ± 21.88 among females in both the intervention and reference areas. Similar changes were observed among males. The mean diastolic blood pressure (DBP) and triglycerides decreased significantly in the intervention area and increased significantly in the reference area in both sexes. High density protein cholesterol (HDL-C) was decreased in both sexes, from 2001 to 2007, in both areas. A strong relationship between tobacco control with high SBP and hypertriglyceridemia was found (P < 0.01).
Conclusion:
Lifestyle improvement programs could be useful to improve the MetS status among men and women.
doi:10.4103/2277-9175.156645
PMCID: PMC4434446  PMID: 26015910
Iranian adults; lifestyle modification; metabolic syndrome
25.  The effect of pioglitazone on circulating interleukin-10 and tumor necrosis factor-alpha levels in a patient with metabolic syndrome: A randomized, double-blind controlled trial 
ARYA Atherosclerosis  2015;11(1):36-42.
BACKGROUND
This study aimed to evaluate the effect of pioglitazone as an insulin sensitizer on circulating interleukin-10 (IL-10) as an anti-inflammatory factor and tumor necrosis factor-alpha (TNF-α) as main proinflammatory factor in non-diabetic metabolic syndrome (MetS) patients in Caucasians race of Middle East area in Iran.
METHODS
We conducted a randomized double-blind controlled study of 68 non-diabetic patients with MetS. Patients were randomly divided into two groups including intervention group received pioglitazone 30 mg daily for 24 weeks, and the control group received placebo pills for the same duration. Circulating levels of TNF-α and IL-10 were assessed as a primary goal. Lipid profile, liver enzymes, blood pressure (BP), waist circumference, and body mass index (BMI) also were measured.
RESULTS
Lipid profile and fasting blood sugar had non-significant changes after treatment by pioglitazone, but BMI was increased significantly (P = 0.002). BP and waist circumference had a significant decrease in both groups (P < 0.050). Aspartate transaminase and alanine transaminase were decreased significantly in the pioglitazone group (P = 0.002). TNF-α decreased non-significantly in both groups (P > 0.050). IL-10 increased in intervention group non-significantly (P = 0.971); whereas in placebo group decreased to a little extent (P = 0.401). C-reactive protein was also decreased insignificant after receive pioglitazone (P = 0.333). There was no significant difference in all variables between the two groups (P > 0.050) except liver enzymes (P < 0.050).
CONCLUSION
This study indicates that the pioglitazone has no positive effect on improving inflammatory status in the non-diabetes patients with MetS.
PMCID: PMC4460351  PMID: 26089929
Pioglitazone; Interleukin-10; Tumor Necrosis Factor Alpha

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