The Relationship between Nocturnal Dipping Status, Morning Blood Pressure Surge, and Hospital Admissions in Patients with Systolic Heart Failure. / A Relação entre o Estado Dipping Noturno, Aumento da Pressão Arterial Matinal e Internações Hospitalares em Pacientes com a Insuficiência Cardíaca Sistólica.

BACKGROUND: Hypertension is a known risk factor for developing heart failure. However, there is limited data to investigate the association between morning blood pressure surge (MBPS), dipping status, echocardiographic parameters, and hospital admissions in patients with systolic heart failure. OBJECTIVES: To evaluate the relationship between morning blood pressure surge, non-dipper blood pressure pattern, echocardiographic parameters, and hospital admissions in patients with systolic heart failure. METHODS: We retrospectively analyzed data from 206 consecutive patients with hypertension and a left ventricular ejection fraction below 40%. We divided the patients into two groups according to 24-hour ambulatory blood pressure monitoring (ABPM) results: dippers (n=110) and non-dippers (n=96). Morning blood pressure surge was calculated. Echocardiographic findings and hospital admissions during follow-up were noted. Statistical significance was defined as p < 0.05. RESULTS: The study group comprised 206 patients with a male predominance and mean age of 63.5 ± 16.1 years. The non-dipper group had significantly more hospital admissions compared to dippers. There was a positive correlation between MBPS and left atrial volume index (r=0.331, p=0.001), the ratio between early mitral inflow velocity and flow propagation velocity (r= 0.326, p=0.001), and the ratio between early mitral inflow velocity and mitral annular early diastolic velocity (E/Em) (r= 0.314, p=0.001). Non-dipper BP, MBPS, and E/Em pattern were found to be independently associated with increased hospital admissions. CONCLUSION: MBPS is associated with diastolic dysfunction and may be a sensitive predictor of hospital admission in patients with systolic heart failure.

FUNDAMENTO: A hipertensão é um fator de risco conhecido para o desenvolvimento de insuficiência cardíaca. No entanto, há dados limitados para investigar a associação entre pico de pressão arterial matinal (PPAM), estado dipper, parâmetros ecocardiográficos e internações hospitalares em pacientes com insuficiência cardíaca sistólica. OBJETIVOS: Avaliar a relação entre aumento matinal da pressão arterial, padrão de pressão arterial não-dipper, parâmetros ecocardiográficos e internações hospitalares em pacientes com insuficiência cardíaca sistólica. MÉTODOS: Analisamos retrospectivamente os dados de 206 pacientes consecutivos com hipertensão e fração de ejeção do ventrículo esquerdo abaixo de 40%. Dividimos os pacientes em dois grupos de acordo com os resultados da monitoramento ambulatorial da pressão arterial (MAPA) de 24 horas: dippers (n=110) e não-dippers (n=96). O aumento matinal da pressão arterial foi calculado. Achados ecocardiográficos e internações hospitalares durante o acompanhamento foram anotados. A significância estatística foi definida como p < 0,05. RESULTADOS: O grupo de estudo foi composto por 206 pacientes com predominância do sexo masculino e idade média de 63,5 ± 16,1 anos. O grupo não-dipper teve significativamente mais internações hospitalares em comparação com os dippers. Houve correlação positiva entre PPAM e índice de volume do átrio esquerdo (r=0,331, p=0,001), relação entre velocidade de influxo mitral precoce e velocidade de propagação do fluxo (r= 0,326, p=0,001) e relação entre influxo mitral precoce velocidade e velocidade diastólica inicial do anel mitral (E/Em) (r= 0,314, p=0,001). Verificou-se que a PA não-dipper, PPAM e o padrão E/Em estão independentemente associados ao aumento das admissões hospitalares. CONCLUSÃO: O PPAM está associado à disfunção diastólica e pode ser um preditor sensível de internação hospitalar em pacientes com insuficiência cardíaca sistólica.

A Relação entre o Estado Dipping Noturno, Aumento da Pressão Arterial Matinal e Internações Hospitalares em Pacientes com a Insuficiência Cardíaca Sistólica / The Relationship between Nocturnal Dipping Status, Morning Blood Pressure Surge, and Hospital Admissions in Patients with Systolic Heart Failure

Resumo Fundamento A hipertensão é um fator de risco conhecido para o desenvolvimento de insuficiência cardíaca. No entanto, há dados limitados para investigar a associação entre pico de pressão arterial matinal (PPAM), estado dipper, parâmetros ecocardiográficos e internações hospitalares em pacientes com insuficiência cardíaca sistólica. Objetivos Avaliar a relação entre aumento matinal da pressão arterial, padrão de pressão arterial não-dipper, parâmetros ecocardiográficos e internações hospitalares em pacientes com insuficiência cardíaca sistólica. Métodos Analisamos retrospectivamente os dados de 206 pacientes consecutivos com hipertensão e fração de ejeção do ventrículo esquerdo abaixo de 40%. Dividimos os pacientes em dois grupos de acordo com os resultados da monitoramento ambulatorial da pressão arterial (MAPA) de 24 horas: dippers (n=110) e não-dippers (n=96). O aumento matinal da pressão arterial foi calculado. Achados ecocardiográficos e internações hospitalares durante o acompanhamento foram anotados. A significância estatística foi definida como p < 0,05. Resultados O grupo de estudo foi composto por 206 pacientes com predominância do sexo masculino e idade média de 63,5 ± 16,1 anos. O grupo não-dipper teve significativamente mais internações hospitalares em comparação com os dippers. Houve correlação positiva entre PPAM e índice de volume do átrio esquerdo (r=0,331, p=0,001), relação entre velocidade de influxo mitral precoce e velocidade de propagação do fluxo (r= 0,326, p=0,001) e relação entre influxo mitral precoce velocidade e velocidade diastólica inicial do anel mitral (E/Em) (r= 0,314, p=0,001). Verificou-se que a PA não-dipper, PPAM e o padrão E/Em estão independentemente associados ao aumento das admissões hospitalares. Conclusão O PPAM está associado à disfunção diastólica e pode ser um preditor sensível de internação hospitalar em pacientes com insuficiência cardíaca sistólica.

Abstract Background Hypertension is a known risk factor for developing heart failure. However, there is limited data to investigate the association between morning blood pressure surge (MBPS), dipping status, echocardiographic parameters, and hospital admissions in patients with systolic heart failure. Objectives To evaluate the relationship between morning blood pressure surge, non-dipper blood pressure pattern, echocardiographic parameters, and hospital admissions in patients with systolic heart failure. Methods We retrospectively analyzed data from 206 consecutive patients with hypertension and a left ventricular ejection fraction below 40%. We divided the patients into two groups according to 24-hour ambulatory blood pressure monitoring (ABPM) results: dippers (n=110) and non-dippers (n=96). Morning blood pressure surge was calculated. Echocardiographic findings and hospital admissions during follow-up were noted. Statistical significance was defined as p < 0.05. Results The study group comprised 206 patients with a male predominance and mean age of 63.5 ± 16.1 years. The non-dipper group had significantly more hospital admissions compared to dippers. There was a positive correlation between MBPS and left atrial volume index (r=0.331, p=0.001), the ratio between early mitral inflow velocity and flow propagation velocity (r= 0.326, p=0.001), and the ratio between early mitral inflow velocity and mitral annular early diastolic velocity (E/Em) (r= 0.314, p=0.001). Non-dipper BP, MBPS, and E/Em pattern were found to be independently associated with increased hospital admissions. Conclusion MBPS is associated with diastolic dysfunction and may be a sensitive predictor of hospital admission in patients with systolic heart failure.

Coronary Endarterectomy: Postoperative Angiographic Results.

OBJECTIVE: To compare the postoperative graft patency rates of patients who had undergone coronary endarterectomies (CE) during coronary bypass surgery to those of patients who had not had CE, based on postoperative coronary angiography. STUDY DESIGN: Comparative descriptive study. PLACE AND DURATION OF STUDY: Coronary Angiography Unit, Tinaztepe University Faculty of Medicine, Turkey, from November 2010 through June 2021. METHODOLOGY: Patients who had undergone CE during coronary bypass surgery were included. Postoperative morbidity results and the patency rates of the vessels with and without endarterectomy were evaluated via coronary angiographies that had been performed. RESULTS: The patency rate in vessels that underwent coronary endarterectomy was determined to be 73.4% according to coronary angiographies performed after an average of 47.7 months. The patency rate in vessels without endarterectomy was 63.7%. The highest patency rate was found in the left anterior descending artery (LAD) in both CE and conventional bypass coronary arteries and the lowest patency rate was found in the diagonal artery (D) in both CE and conventional bypass coronary arteries. In the comparison of vessels with and without CE, the patency rate was found to be 66.6% in patients with CE on the right coronary artery (RCA) and 45.7% in patients without CE on the right coronary artery and the difference was statistically significant (p<0.037). CONCLUSION: Coronary endarterectomy should be used when it is believed that a simple anastomosis would not provide adequate patency during coronary bypass surgery because the primary goal should be to achieve full revascularization and a long-term patency rate. KEY WORDS: Coronary angiography, Coronary bypass grafting, Endarterectomy, Patency rate.

Association of Epicardial Fat Tissue with Coronary Artery Disease and Left Ventricle Diastolic Function Indicators.

BACKGROUND Epicardial fat tissue (EAT) acts as brown adipose tissue and protects the heart and coronary arteries against hypothermia. Recent studies demonstrated that EAT is a source of both anti-inflammatory and atherogenic cytokines. In this study, our aim was to investigate the association of vertical, horizontal, and area measurements of EAT thickness and their association with coronary artery disease, diastolic function, and myocardial performance index in patients who underwent coronary angiography. MATERIAL AND METHODS The study population consisted of patients who presented to our outpatient clinic with chest pain and whose non-invasive stress tests were positive between June 2015 and July 2017. Echocardiographic examinations were performed prior to the angiography. Coronary angiograms were performed using Judkins method from the femoral artery. RESULTS Mean vertical thickness of EAT was 0.6 cm in patients with CAD and 0.46 cm in those without CAD (p=0.0001). Mean horizontal length of EAT was 2.91 cm in patients with CAD and was 2.41 cm in the subjects without CAD (p=0.001). ROC analysis showed 81% sensitivity and 53% specificity for a cut-off value of 0.45, and 67% sensitivity and 71% specificity for a cut-off value of 0.55 for EAT vertical (cm). Multivariate analysis showed that EAT is an independent risk factor for coronary artery disease. CONCLUSIONS Echocardiography is an inexpensive routine assessment for most patients. EAT thickness determined by echocardiography may be a useful indicator of increased CAD risk, but not diastolic dysfunction, of the left ventricle.

Thiol/Disulfide Balance in Patients with Familial Hypercholesterolemia.

OBJECTIVE: Herein, we investigated the balance of thiol/disulfide, with the hypothesis that the balance between disulfides and thiols, which are natural antioxidants, might be disrupted in patients with familial hypercholesterolemia, which eventually leads to endothelial damage. METHODS: In this study, we evaluated 51 patients diagnosed with familial hypercholesterolemia and 81 healthy subjects. Blood samples were taken from the patients after a minimum of 12 hours of fasting; samples were immediately centrifuged, stored in Eppendorf tubes, and preserved at -80°C. RESULTS: This study found that thiol levels are significantly lower in patients with familial hypercholesterolemia, whereas disulfide levels are higher (independent of age, gender, and body mass index). This means that in such patients, the thiol/disulfide balance changes in favour of disulfide. CONCLUSIONS: In this study, we found that the thiol/disulfide balance in patients with familial hypercholesterolemia is disrupted in favour of disulfide.

Relationship between alkaline phosphatase and impaired coronary flow in patients with ST-segment elevated myocardial infarction.

Objective Recent studies have shown that alkaline phosphatase (ALP) might play a negative role in clinical outcomes of patients with peripheral and coronary artery disease. This study aimed to investigate the relationship between serum ALP levels and coronary thrombolysis in myocardial infarction (TIMI) frame counts in patients with ST-segment elevated myocardial infarction undergoing primary percutaneous coronary intervention (PCI). Methods A total of 198 patients were enrolled in the current study. Serum ALP levels were measured in lithium-heparin plasma samples via a standardized, colorimetric enzyme assay. Coronary TIMI flow was evaluated by counting the number of cine frames that were required for contrast to reach a standardized distal coronary landmark in the culprit vessel. Results The Spearman correlation coefficient test showed strong positive relationships between coronary TIMI frame counts after primary PCI and serum ALP levels on admittance for the left anterior descending, circumflex, and right coronary arteries (r = 0.774, r = 0.831, and r = 0.730, respectively). Conclusion Elevated serum ALP levels appear to be a predictor of impaired coronary TIMI frame count in patients suffering from ST-segment elevated myocardial infarction.

Are P Wave and QT Dispersions Related to Severe Peripheral Artery Disease?

BACKGROUND The aim of this study was to evaluate the relationship between P wave and QT dispersions (PWD and QTD) during the course of severe peripheral artery disease (PAD). MATERIAL AND METHODS We recruited 163 patients who underwent peripheral angiography (PA) between August 2011 and March 2017, and they were divided into 2 groups according to the severity of PAD on PA. PWD and QTD were investigated using 12-lead electrocardiograms. Group One consisted of patients diagnosed with <70% stenosis on PA, who eventually received medical treatment; Group Two consisted of patients diagnosed with ≥70% stenosis on PA, who eventually underwent surgery. RESULTS ROC curve analysis of the 2 groups demonstrated that PWD was significantly higher in Group Two (AUC: 0.913505; 95% confidence interval (CI): 0.859365 to 0.951788; p<0.0001). The Youden index showed that a cut-off PWD value of >35 msn predicted a peripheral artery stenosis of ≥70% with a sensitivity of 88.89% and a specificity of 85.37% (+LR: 6.07, -LR: 0.13). Moreover, QTD was significantly higher in Group Two (AUC: 0.884749; 95% CI: 0.825489 to 0.929391; p<0.0001). Youden index showed that a cut-off QTD value of >75 msn predicted a peripheral artery stenosis of ≥70% with a sensitivity of 76.54% and a specificity of 85.37% (+LR: 5.23, -LR: 0.27). Comparison of ROC curves showed no difference in terms of predicting peripheral artery stenosis of ≥70% between PWD and QTD (p=0.3308). CONCLUSIONS Interpreting PWD and QTD offers a non-invasive and cost-effective assessment method for detecting patients at high risk for coronary artery disease in the context of severe PAD.

Effect of Heart Rate-Oriented Therapy on Diastolic Functions in Patients with Heart Failure with Reduced Ejection Fraction.

BACKGROUND: Resting heart rate (HR) is a strong predictor of cardiovascular mortality and morbidity in patients with heart failure with reduced ejection fraction (HFrEF). However, the effects of HR-lowering therapy on diastolic function in HFrEF patients are not well described. In this study, we aimed to investigate the effect of lowering HR on diastolic function in HFrEF patients with sinus rhythm. METHODS: Fifty patients with HFrEF with coexisting diastolic dysfunction and sinus rhythm with resting HR > 70 bpm were prospectively included in the study. All patients were treated with intended HR-lowering therapy, which targeted a HR below 70 bpm. We divided the whole population according to the resting HR achieved with strict rate control (group 1) and to that achieved without strict rate control (group 2; HR > 70 bpm) at the end of the study. Left ventricular diastolic function and B-type natriuretic peptide (BNP) values at baseline and at the end of the study were compared in both groups. RESULTS: No significant differences were found between the groups in terms of baseline parameters except for lower diastolic blood pressure in group 2. At the end of follow-up, E/Em ratio, E/A ratio and left atrial area significantly decreased with an increased deceleration time in group 1. The changes in HR (delta HR) were correlated with E/Em (r = 0.67, p < 0.001) and delta BNP level (r = 0.49, p < 0.001). CONCLUSIONS: No significant differences were found between the groups in terms of baseline parameters except for lower diastolic blood pressure in group 2. At the end of follow-up, E/Em ratio, E/A ratio and left atrial area significantly decreased with an increased deceleration time in group 1. The changes in HR (delta HR) were correlated with E/Em (r = 0.67, p < 0.001) and delta BNP level (r = 0.49, p < 0.001).

Left ventricular twist was decreased in isolated left bundle branch block with preserved ejection fraction.

OBJECTIVE: Left ventricular (LV) rotation and twist play an important role in LV contraction and relaxation. Left bundle branch block (LBBB) deteriorates both diastolic and systolic functions. We evaluated the LV twist in patients with LBBB and preserved ejection fraction (EF) (>50%) to determine twist as a potential marker for subtle myocardial dysfunction. METHODS: This observational cross-sectional study included 34 LBBB patients with preserved EF who were free from ischemic and valvular disease (Group 1) and 36 healthy controls (Group 2). All patients underwent 2-D Doppler and 2-D speckle tracking echocardiography. LV apical, basal rotation, and twist were evaluated in both groups and compared accordingly. In addition, subjects were dichotomized considering the median twist value of the study population. Binary logistic regression analysis was performed to determine the independent variables associated with inframedian twist. RESULTS: Baseline clinical characteristics were similar in LBBB patients and controls. Mean apical rotation (2.5°±1.9° vs. 4.4°±2.9°; p=0.002), basal rotation (-2.9°±2.3° vs. -4.1°±2.7°; p=0.05), and twist (5.4°±3° vs. 8.6°±3.3°; p<0.001) were decreased in group 1. Parameters related to intra- and interventricular mechanical dyssynchrony, such as longitudinal left ventricular dyssynchrony index (LVdys) and preejection interval of LV, interventricular mechanical delay (IVMD), and left posterior wall contractions (SPMWD) were significantly higher in the LBBB group. The median twist value of the studied population was 6.65°. Binary logistic regression analysis showed that only presence of LBBB was independently associated with inframedian twist (OR=6.250; 95% CI: 2.215-17.632; p<0.001). CONCLUSION: The LBBB might have induced the reduction of LV twist by diminishing the LV rotation before inducing a prominent effect on the left ventricular ejection fraction (LVEF). Therefore, twist may be considered as a marker for subtle LV dysfunction in LBBB with substantially normal EF.

Renal Subcapsular Hematoma Caused by Hydrophilic Guide Wire during Patent Ductus Arteriosus Closure.

Hydrophilic guide wire-associated renal subcapsular hematoma (RSH) during patent ductus arteriosus (PDA) closure is an extremely rare clinical condition. Herein, we present the case of a 16-year-old adolescent who suffered accidental hydrophilic 0.035-inch guide wire-related RSH during PDA closure. This RSH was diagnosed by computerized tomography and selective renal angiography. It was successfully treated by conservative treatment.

Endovascular Treatment of Renal Artery Stenosis due to Fibromuscular Dysplasia - Is Stent Implantation Underused in this Circumstance?

Fibromuscular dysplasia (FMD) is a nonatherosclerotic and noninflammatory arterial disease that commonly affects the renal and carotid arteries. The primary target in treating patients with renal artery FMD is the control of blood pressure in order to prevent end-organ damage, which can be caused by poorly controlled hypertension. Invasive endovascular treatment should be taken into consideration both when hypertension cannot be controlled with medication. According to current opinion, hypertension attributed to renal artery FMD is often successfully treated solely with percutaneous renal balloon angioplasty (PRBA), with no requirement for stent implantation under most circumstances. However, an FMD recurrence after PRBA occurs frequently in these patients.

Acute Effusive Pericarditis due to Horse Chestnut Consumption.

BACKGROUND: There are many well-known causes of pericardial effusion, such as cancer metastasis, bacterial or viral pericarditis, and uremic pericarditis; however, no reports exist in the literature demonstrating a pericardial effusion that led to cardiac tamponade following consumption of an herbal remedy. CASE REPORT: A 32-year-old male patient was referred to our cardiology outpatient clinic with a complaint of dyspnea. The patient's medical history was unremarkable; however, he had consumed 3 boxes of horse chestnut (Aesculus hippocastanum L) paste over the previous 1.5 months. His chest x-ray examination revealed an enlarged cardiac shadow and bilateral pleural effusion. On transthoracic echocardiographic examination, his ejection fraction was found to be 55% with circumferentially extended pericardial effusion that reached 3.9 cm at its maximal thickness. No growth had been detected in the pericardial and pleural biopsies or blood samples; there was no evidence of an infectious process in the physical examination. Based on this information, we diagnosed pericarditis resulting from the use of herbal remedies. This is the first report to demonstrate that herbal remedy consumption may cause this type of clinical condition. CONCLUSIONS: Besides other well-known causes, pericardial effusion related to the consumption of herbal remedies should always be considered when treating patients with pericardial effusion caused by unclear etiologies.

An investigation of pulse transit time as a blood pressure measurement method in patients undergoing carotid artery stenting.

INTRODUCTION: Pulse transit time (PTT) is the duration that a pulse wave takes to travel between two different arterial points, and it may be useful in estimating blood pressure. The aim of this study was to investigate the PTT during carotid artery stenting, as well as its value in blood pressure estimation. METHOD: Thirty-four patients with critical carotid artery stenosis were enrolled in this study. The carotid PTT from the onset of the R-wave of electrocardiography to the pulse waveform at the carotid artery, obtained invasively during carotid artery catheterization, was measured. The carotid PTT was measured before and after stenting of the internal carotid artery. RESULTS: The mean age was 70.4±8.0 years among the 34 patients enrolled (eight female patients, 21.9%). Measurements were obtained before and after carotid artery stenting. The heart rate (85.9±15.9 vs. 76.9±12.5 bpm, P<0.01), systolic blood pressure (162.8±28.6 vs. 126.0±31.7 mmHg, P<0.001), diastolic blood pressure (87.7±17.9 vs. 76.9±20.0 mmHg, P<0.01), and mean blood pressure (112.7±18.6 vs. 93.2±22.7 mmHg, P<0.001) were significantly decreased, whereas the carotid PTT (0.06±0.012 s vs. 0.07±0.012 s, P<0.001) was significantly increased after carotid stenting. The difference between the PTTs was negatively correlated with the systolic blood pressure (r=-0.35, P=0.02) and diastolic blood pressure (r=-0.4, P=0.01). CONCLUSION: After carotid stenting, the PTT increases significantly because of the lowering of the blood pressure. However, the relationship is not strong enough for the PTT to be used for blood pressure estimation.

Predictive value of platelet-to-lymphocyte ratio in severe degenerative aortic valve stenosis.

BACKGROUND: Aortic valve stenosis (AVS) is the most common cause of left ventricular outflow obstruction, and its prevalence among elderly patients causes a major public health burden. Recently, platelet-to-lymphocyte ratio (PLR) has been recognized as a novel prognostic biomarker that offers information about both aggregation and inflammation pathways. Since PLR indicates inflammation, we hypothesized that PLR may be associated with the severity of AVS due to chronic inflammation pathways that cause stiffness and calcification of the aortic valve. MATERIALS AND METHODS: We retrospectively enrolled 117 patients with severe degenerative AVS, who underwent aortic valve replacement and 117 control patients in our clinic. PLR was defined as the absolute platelet count divided by the absolute lymphocyte count. Severe AVS was defined as calcification and sclerosis of the valve with a mean pressure gradient of >40 mmHg. RESULTS: PLR was 197.03 ± 49.61 in the AVS group and 144.9 ± 40.35 in the control group, which indicated a statistically significant difference (P < 0.001). A receiver operating characteristic (ROC) curve analysis demonstrated that PLR values over 188 predicted the severity of aortic stenosis with a sensitivity of 87% and a specificity of 70% (95% confidence interval = 0.734-0.882; P < 0.001; area under ROC curve: 0.808). CONCLUSION: We suggest that the level of PLR elevation is related to the severity of degenerative AVS, and PLR should be used to monitor patients' inflammatory responses and the efficacy of treatment, which will lead us to more closely monitor this high-risk population to detect severe degenerative AVS at an early stage.

Does "smoker's paradox" exist in clopidogrel-treated Turkish patients with acute coronary syndrome.

Previously conducted studies revealed that smoking enhanced the efficacy of clopidogrel by increasing formation of the active metabolite (AM) from the prodrug through induction of the cytochrome CYP1A2. The expression of cytochrome enzymes depends on genotype and no data exists in literature conducted in Turkish patients comparing the clopidogrel responsiveness between active smokers and non-active smokers treated with clopidogrel. In this study, our aim was to investigate the clopidogrel responsiveness in clopidogrel-treated Turkish acute coronary syndrome (ACS) patients according to their smoking status. We retrospectively enrolled 258 patients who were hospitalized due to ACS. Clinical variables of the patients, especially smoking status were recorded. Clopidogrel resistance was evaluated by using adenosine diphosphate (ADP) induced platelet aggregometry. Clopidogrel resistance was detected as a change in maximal aggregation ≤20% from baseline. A total of 139 patients were active smokers while 12 were former smokers. 107 patients did not have a history of smoking. Ten of the smokers were hyporesponsive to clopidogrel, whereas 36 of non-smokers were hyporesponsive to clopidogrel (p < 0.001). Receiver-operating characteristic curve analysis demonstrated that Au-min value >612.5 predicted the clopidogrel resistance with a sensitivity of 60% (OR: 100.65, %95 CI = 19.996-506.615 p < 0.001). Results of this study demonstrated that ADP responses were lower in smokers receiving clopidogrel and aspirin than in non-smokers receiving the same drug regimen. This finding indicates that smoking was related to an enhanced clopidogrel responsiveness in Turkish patients hospitalized due to ACS, suggesting that "smoker's paradox" probably exists in Turkish ACS patients.