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Atrial fibrillation (AF)/atrial flutter (AFL) is the most common cardiac tachyarrhythmia, with an increasing trend in its burden in recent years. However, the burden of AF/AFL in Iran remains unclear. This study aimed to estimate the burden of AF/AFL and its attributable risk factors from 1990 to 2019 at national and subnational levels. Using the comparative risk assessment method of the Global Burden of Disease (GBD) Study 2019, we extracted data on AF/AFL incidence, prevalence, deaths, disability-adjusted life years (DALYs), and their age-standardized rates from 1990 to 2019 and analyzed them based on by age, sex, and socio-demographic index (SDI). The percentage contribution of AF/AFL major risk factors was calculated. Moreover, the AF/AFL burden in 2050 was projected using the United Nations world population prospect data. In 2019, there were 339.1 (259.4–433.7) thousand AF/AFL patients in Iran, with 30.2 (23.2–38.5) thousand new cases, 1.7 (1.5–2) thousand deaths and 48 (37.7–60.5) thousand DALYs. Females and 50–69-year-old patients recorded a higher burden for AF/AFL; however, the increasing trend was more pronounced in males and more than 85-year-old patients. High systolic blood pressure and elevated body mass index (BMI) were the predominant attributable risk factors for AF/AFL-related deaths and DALYs. It is estimated that in 2050, the number of AF/AFL patients will increase to 1.1 million people, the incidence of AF/AFL will increase to 91 thousand patients, and the number of AF/AFL-related deaths and DALYs will surge to 7.2 and 170.8 thousand, respectively. Despite advancements in prevention and treatment, AF/AFL remains a major public health problem in Iran. Given its largely preventable and treatable nature, more cost-effective strategies are required to target modifiable risk factors, especially within susceptible age and sex groups.

ObjectiveThe outcome of rhinoplasty was evaluated in patients undergoing tongue-in-groove technique (TIG) with and without septal extension grafts (SEG) placement for stabilization of nasal tip rotation.Subjects and MethodsThree hundred and sixty-seven patients who underwent rhinoplasty using TIG from 2016 to 2020 were included in this study. SEG was used if the caudal segment of the septum was not suitable for TIG. All patients were photographed pre- and postoperatively. Columellar Facial angle (CFA) and Nasolabial angle (NLA) were measured preoperatively at three intervals including up to six months after the operation (early or T1), up to one year after T1 (midterm or T2), and up to two years after T2 (late or T3).ResultsTwo hundred and nine patients (56.94%) underwent TIG and the rest of them (43.06%) received SEG plus TIG (SEG+TIG). The TIG group had a mean CFA of 95.9±7.56 degrees preoperatively, 106.5±6.77 degrees at T1, 105.4±6.48 degrees at T2, and 104.8 ±7.52 at T3. The SEG+TIG had a mean CFA of 98.9±7.65 degrees preoperatively, 108.8±6.58 degrees at T1, 107.7±6.86 degrees at T2, and 106.2 ±15.6 at T3. Comparison of T1, T2, and T3 showed that the CFA changes were less than 1%, indicating a nonsignificant difference. The same results were obtained for NLA as well.ConclusionAdding of SEG to TIG may be an effective technique to create and maintain a stable rotation comparing to TIG independently.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Sleep duration has been suggested to be associated with hypertension (HTN). However, evidence of the nature of the relationship and its direction has been inconsistent. Therefore, we performed a meta-analysis to assess the relationship between sleep duration and risk of HTN incidence, and to distinguish more susceptible populations. PubMed, Embase, Scopus, Web of Science, and ProQuest were searched from January 2000 to May 2023 for cohort studies comparing short and long sleep durations with 7-8 hours of sleep for the risk of HTN incidence. Random-effect model (the DerSimonian-Laird method) was applied to pool risk ratios (RR) and 95% confidence interval (CI). We included sixteen studies ranging from 2.4 to 18 years of follow-up duration evaluating HTN incidence in 1,044,035 people. Short sleep duration was significantly associated with a higher risk of developing HTN (HR: 1.07, 95% CI: 1.06-1.09). The association was stronger when the sleep duration was less than 5 hours (HR: 1.11, 95% CI: 1.08-1.14). In contrast to males, females (HR: 1.07, 95% CI: 1.04-1.09) were more vulnerable to developing HTN due to short sleep duration. No significant difference between different follow-up durations and age subgroups was observed. Long sleep duration was not associated with an increased incidence of HTN. Short sleep duration was associated with higher risk of HTN incidence, however, there was no association between long sleep duration and incidence of HTN. These findings highlight the importance of implementing target-specific preventive and interventional strategies for vulnerable populations with short sleep duration to reduce the risk of HTN.

Background The prevalence and burden of substance and opium use have increased worldwide over the past decades. In light of rapid population changes in Tehran, we aimed to evaluate the prevalence of opium and other substance use among adult residents in Tehran, Iran. Method From March 2016 to March 2019, we utilized data from 8 296 participants in the Tehran Cohort Study recruitment phase (TeCS). We calculated the age-sex-weighted prevalence of substance use and the geographic distribution of substance use in Tehran. We also used logistic regression analysis to determine possible determinants of opium use. Result We analyzed data from 8 259 eligible participants with complete substance use data and the average age of participants was 53.7 ± 12.75 years. The prevalence of substance use was 5.6% (95% confidence interval [CI]: 4.6- 7.1%). Substance use was more common in males than females (Prevalence: 10.5% [95% CI: 8.6- 12.6%] vs. 0.5% [95% CI: 0.2- 1.2%], respectively). The age-sex weighted prevalence of substance use was 5.4% (95% CI: 4.6-7.1%). Moreover, opium was the most frequently used substance by 95.8% of substance users. Additionally, we found that male gender (Odds ratio [OR]: 12.1, P  < 0.001), alcohol intake (OR: 1.3, P  = 0.016), and smoking (OR: 8.5, P  < 0.001) were independently associated with opium use. Conclusions We found that the prevalence of substance use in Tehran was 5.6%, and opium was the most frequently used substance. In addition, male gender, lower levels of education, alcohol, and tobacco consumption are the main risk factors for substance use in Tehran. Healthcare providers and policymakers can utilize our results to implement preventive strategies to minimize substance use in Tehran.

Background It remains controversial whether adding ezetimibe to low/moderate‐intensity statins has a more beneficial impact on the treatment efficacy and safety of patients with existing atherosclerotic cardiovascular disease (ASCVD) compared to high‐intensity statin regimens. Hypothesis A combination of low/moderate‐intensity statins plus ezetimibe might be more effective and safer than high‐intensity statin monotherapy. Methods We searched databases for randomized controlled trials comparing lipid profile alterations, drug‐related adverse events, and MACE components between high‐intensity statin monotherapy and low/moderate‐intensity statin plus ezetimibe combination therapy. Pooled risk ratios (RR), mean differences (MD), and 95% confidence intervals (95% CI) were estimated using a random‐effects model. Results Our comprehensive search resulted in 32 studies comprising 6162 patients treated with monotherapy against 5880 patients on combination therapy. Combination therapy was more effective in reducing low‐density lipoprotein cholesterol (LDL‐C) levels compared to monotherapy (MD = −6.6, 95% CI: −10.6 to −2.5); however, no significant differences were observed in other lipid parameters. Furthermore, the combination therapy group experienced a lower risk of myalgia (RR = 0.27, 95% CI: 0.13–0.57) and discontinuation due to adverse events (RR = 0.61, 95% CI: 0.51–0.74). The occurrence of MACE was similar between the two treatment groups. Conclusions Adding ezetimibe to low/moderate‐intensity statins resulted in a greater reduction in LDL‐C levels, a lower rate of myalgia, and less drug discontinuation compared to high‐intensity statin monotherapy in patients with existing cardiovascular disease. However, according to our meta‐analysis, the observed reduction in LDL‐C levels in the combination group did not correlate with a reduction in MACE compared to the high‐intensity statin group. Based on 32 RCTs, we compared the safety and effectiveness of combination therapy with ezetimibe and low/moderate‐intensity statin to high‐intensity statin monotherapy in patients with a history of atherosclerotic cardiovascular disease. The combination therapy demonstrated a greater LDL‐C reduction and fewer cases of myalgia and discontinuation due to drug‐related adverse events. Summary Combination therapy of low/moderate‐intensity statin with ezetimibe led to a greater reduction in LDL‐C levels, a lower rate of myalgia, and less drug discontinuation compared to high‐intensity statin monotherapy, but no significant effect on MACE components.

Purpose This systematic review aimed to evaluate the effect of transcutaneous auricular vagus nerve stimulation on heart rate variability and baroreflex sensitivity in healthy populations. Method PubMed, Scopus, the Cochrane Library, Embase, and Web of Science were systematically searched for controlled trials that examined the effects of transcutaneous auricular vagus nerve stimulation on heart rate variability parameters and baroreflex sensitivity in apparently healthy individuals. Two independent researchers screened the search results, extracted the data, and evaluated the quality of the included studies. Results From 2458 screened studies, 21 were included. Compared with baseline measures or the comparison group, significant changes in the standard deviation of NN intervals, the root mean square of successive RR intervals, the proportion of consecutive RR intervals that differ by more than 50 ms, high-frequency power, low-frequency to high-frequency ratio, and low-frequency power were found in 86%, 75%, 69%, 47%, 36%, and 25% of the studies evaluating the effects of transcutaneous auricular vagus nerve stimulation on these indices, respectively. Baroreflex sensitivity was evaluated in six studies, of which a significant change was detected in only one. Some studies have shown that the worse the basic autonomic function, the better the response to transcutaneous auricular vagus nerve stimulation. Conclusion The results were mixed, which may be mainly attributable to the heterogeneity of the study designs and stimulation delivery dosages. Thus, future studies with comparable designs are required to determine the optimal stimulation parameters and clarify the significance of autonomic indices as a reliable marker of neuromodulation responsiveness. Graphical abstract

BackgroundSeveral surgical techniques used for rhinoplasty can change the upper lip form over the long term. By eliminating the membranous septum and causing dysfunction of the depressor septi nasi muscle and performing other maneuvers, the tongue-in-groove (TIG) technique can exaggerate changes in the upper lip shape, length, and slope.MethodsThis study was conducted to compare the effects of the TIG technique with and without a septal extension graft (SEG) on lip slope and aesthetic angles on the profile view. A retrospective review was performed on 367 patients who underwent primary rhinoplasty using the TIG technique from 2016 to 2020. The upper lip angle (ULA), the nasolabial angle (NLA), and the columellar facial angle (CFA) were measured for comparison pre-and post-operatively.ResultsOf 367 patients, 209 underwent TIG, while the rest underwent TIG over SEG (TIG+SEG). Comparison of pre-and post-operative ULAs showed significant changes in both groups. Although mean ULAs increased in both groups, some of the patients in each group experienced a decrease in ULA. The percentage of the patients with increased post-operative ULA significantly grow with increase in the pre-operative NLA (p < 0.05). However, no significant correlation was found between pre-operative CFA and post-operative ULA.ConclusionThe present study suggests that TIG with and without SEG can change the lip slope on the profile view, possibly due to the shift of the subnasal point superiorly and posteriorly.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

This study compares the prognostic value of risk factors for Permanent pacemaker implantation (PPI) following transcatheter aortic valve replacement (TAVR). PubMed, Embase, Scopus, and Cochrane Library databases were searched until November 2024 for studies reporting PPI incidence within 30 days post-TAVR. A random-effect model was used to pool risk ratios (RR) and standardized mean differences (SDM) for binary and continuous risk factors. Network meta-analysis estimated pooled risk differences (ΔRR) for binary predictors with male sex as the reference. Significant predictors were ranked based on their surface under the cumulative ranking curve (SUCRA) values. A total of 108 studies comprising 77,538 patients (14,560 requiring PPI) were included. Male sex (RR: 1.13), baseline atrial fibrillation (AF) (RR: 1.12), 2nd degree Mobitz I (RR: 5.16) and Mobitz II (RR: 2.30) atrioventricular blocks (AVB), 3rd degree AVB (RR: 13.46), left anterior (LAHB) (RR: 1.79) and posterior hemiblocks (LPHB) (RR: 2.57), bifascicular block (RR: 2.34), right bundle branch block (RBBB) (RR: 3.20) and intraprocedural AVB (RR: 4.15) were identified as predictors for PPI post-TAVR. The risk of PPI was higher with self-expandable valves (RR: 1.79), subclavian access (RR: 1.75), and 29 mm prostheses (RR: 1.33) compared to balloon-expandable valves, transfemoral access, and 23 mm prostheses. Network meta-analysis ranked 3rd degree AVB (SUCRA <0.01), Mobitz I AVB (SUCRA: 0.14), Mobitz II AVB (SUCRA: 0.33), intraprocedural AVB (SUCRA: 0.42), bifascicular block (SUCRA: 0.48), RBBB (SUCRA: 0.49) and LPHB (SUCRA: 0.54) as major predictors of PPI in descending order of significance. In conclusion, clinicians should closely monitor conduction abnormalities as key predictors of PPI following TAVR. Additionally, other risk factors such as subclavian access, self-expanding implantation, AF, large prosthesis diameter, and male sex should not be overlooked. [Display omitted]

Thirty years ago, patients with low ejection fraction (EF) have often been excluded from rehabilitation programs due to concern about possibility of sudden death or other adverse cardiovascular events during exercise sessions. Recent studies have highlighted the fact that cardiac rehabilitation could improve exercise capacity, cardiac function, and health-related quality of life in congestive heart failure patients. This encouraged us to write a review article and update our latest knowledge about the outcome of rehabilitation program in patients with severely depressed cardiac function. We were particularly interested in effect of cardiac rehabilitation on exercise capacity, quality of life, vascular effects, neuro-hormonal changes, and mortality. We also conducted a mini-systematic review and meta-analysis on randomized controlled trials comparing exercise training with usual care in patients with severely reduced left ventricular ejection fraction, for the mortality subsection to obtain precise estimates of overall treatment benefit on mortality. It is our privilege to submit our manuscript for possible publication in your prestigious journal.

Background Comparisons of outcomes after transcatheter aortic valve replacement with balloon‐expandable (BEV) versus self‐expanding (SEV) valves are limited. Hypothesis This study aimed to compare clinical and hemodynamic outcomes of BEV and SEV at short‐term (30 days), midterm (1 year), and long‐term (> 1 year) endpoints. Methods PubMed, Embase, Scopus, and Cochrane Library databases were searched until July 2024 for randomized controlled trials. Random‐effect model (DerSimonian–Laird method) was used to pool the risk ratios (RR), mean differences, and 95% confidence intervals (CI). Results A total of 10 studies comprising 4325 patients (2295 BEV, 2030 SEV) were included. In short‐term, cardiovascular (RR: 0.56, 95% CI: 0.36–0.87) and all‐cause mortality (RR: 0.54, 95% CI: 0.35–0.81) were lower in the BEV group. Risk of moderate to severe paravalvular leak (PVL) was lower among BEV patients in short‐term (RR: 0.28, 95% CI: 0.17–0.49) and long‐term (RR: 0.28, 95% CI: 0.1–0.79). A limited number of studies showed a greater risk of clinical valve thrombosis on BEV in midterm and long‐term. The need for permanent pacemaker implantation was lower in BEV at both short‐term (RR: 0.56, 95% CI: 0.37–0.87), and midterm (RR: 0.78, 95% CI: 0.64–0.94). The SEV group had a larger effective orifice area with lower mean transvalvular pressure gradient at all endpoints. Conclusions BEV is associated with reduced risk of clinical outcomes in short‐term; however, most differences diminish in longer evaluations, except for moderate to severe PVL, which remains elevated for SEV. SEVs had better hemodynamic results and lower risk of clinical valve thrombosis. By combining data from 10 studies comprising 4325 patients, this study found that balloon‐expandable valves were associated with a reduced risk of adverse clinical outcomes in the short term; which mainly disappeared in longer evaluations. Conversely, self‐expanding valves presented better hemodynamic performance. Summary In short‐term evaluations post‐TAVR, patients with BEV experienced better survival outcomes, but no difference was noted in longer evaluations. The need for permanent pacemaker implantation was also lower in BEV group at short‐term and midterm follow‐up periods. The SEVs had a larger effective orifice area with lower mean transvalvular pressure gradient even at long‐term endpoints post‐TAVR.