Comparison of quantitative and qualitative coronary angiography: computer versus the eye.

OBJECTIVE: Since visual estimation of the extent of vessel stenosis may vary between operators, we aimed in this study to investigate both inter-observer variability and consistency between the estimation of an operator and quantitative coronary analysis (QCA) measurements. METHODS: A total of 147 elective percutaneous coronary intervention patients with 155 lesions between them were consecutively enrolled in the study. These patients were evaluated for visual estimation of lesion severity by three operators. The lesions were also evaluated with QCA by an operator who was blinded to the visual assessments. Reference diameter, minimal lumen diameter, percentage diameter of stenosis, percentage area of stenosis and diameter of lesion length from the proximal lesion-free segment to the distal lesion-free segment were calculated using a computerised QCA software program. RESULTS: There was a moderate degree of concordance in the categories 70-89% (κ: 0.406) and 90-99% (κ: 0.5813), whereas in the categories < 50% and 50-69% there was a low degree of concordance between the visual operators (κ: 0.323 and κ: 0.261, respectively). There was a low to moderate grade of concordance between visual estimation and percentage area of stenosis by QCA (κ: 0.30) but there was no concordance between visual estimation and percentage diameter of stenosis by QCA (κ: -0.061). Also, there was a statistically significant difference between QCA parameters of percentage diameter of stenosis and percentage area of stenosis (58.4 ± 14.5 vs 80.6 ± 11.2 %, p < 0.001). CONCLUSIONS: Visual estimation may overestimate a coronary lesion and may lead to unnecessary coronary intervention. There was low concordance in the categories < 50% and 50-69% between the visual operators. Percentage area of stenosis by QCA had a low to moderate grade of concordance with visual estimation. Percentage area of stenosis by QCA more closely reflected the visual estimation of lesion severity than percentage diameter of stenosis.

One-year results of primary stenting for TASC II D lesions of the superficial femoral and popliteal arteries.

Objective This study aimed to evaluate the safety and the efficacy of primary stenting to treat Trans-Atlantic Inter-Society Consensus II (TASC) D femoropopliteal lesions. Background Advances in wire, balloon and stent design have been reported to improve the durability of stenting of longer femoropopliteal lesions. Methods A total of 57 limbs of 53 patients with Rutherford stage 3 to 6 due to TASC D femoropopliteal lesions were treated with a self-expanding nitinol stent in a prospective, single-centre, observational study. End points of interest included primary and secondary patency, target lesion revascularization, in-stent restenosis, major adverse cardiovascular events, Rutherford class improvement and change in walking capacity at 1 year. Results A total of 53 patients (57 lesions) were treated with a self-expanding nitinol stent and final procedural success was 91.2%. The median length of the treated segment was 330 ± 96 mm. The median stented segment was 366 ± 71 mm and the mean number of the stents was 2.1 ± 0.9. At 1 year, primary and secondary patency rates were 63.9% and 82.1%, respectively. Major adverse cardiovascular events occurred in 11 patients (22.9%), and[[strike_start]] [[strike_end]]significant benefits were observed in Rutherford class and walking distance (both P < 0.001). Conclusions Primary implantation of self-expanding nitinol stents for the treatment of TASC D femoropopliteal lesions appears to be safe and effective, especially in patients who have multiple co-morbidities and a high risk for surgical bypass. The risk of restenosis was higher when long stenting was extended to the popliteal artery.

Comparison of the effects of high-dose atorvastatin and high-dose rosuvastatin on oxidative stress in patients with acute myocardial infarction: A pilot study.

OBJECTIVE: Oxidative stress is increased in patients with acute myocardial infarction (AMI). Statins reduce oxidative stress independent of their effect in reducing low-density lipoprotein cholesterol (LDL-C). The aim of the present study was to compare the effects of atorvastatin and rosuvastatin on oxidative status by investigating serum paraoxonase, serum arylesterase, total oxidant status, total antioxidant status (TAS) and oxidative stress index (OSI) in patients with AMI. METHODS: Seventy patients with AMI were randomized into 2 groups; total of 55 patients (19 females, 36 males) aged 32 to 86 years completed the study and were included in the analysis. Patients were treated with 80 mg atorvastatin or 40 mg rosuvastatin for 4 weeks. Lipid parameters and parameters of oxidative status were measured at admission and after 4-week statin treatment. RESULTS: After 4-week treatment, atorvastatin and rosuvastatin were associated with significant reduction in TAS, OSI, total cholesterol, and LDL-C levels. Serum paraoxonase level was significantly increased in both groups, while high-density lipoprotein cholesterol (HDL-C) level was significantly reduced in atorvastatin group. No statistically significant differences were found between atorvastatin and rosuvastatin in terms of actual difference in oxidative stress parameters. CONCLUSION: Atorvastatin and rosuvastatin have similar effects on oxidative status in patients with AMI. Rosuvastatin affected HDL-C level more favorably than atorvastatin.

Heart rate variability in normal-weight patients with polycystic ovary syndrome.

OBJECTIVE: Polycystic ovary syndrome (PCOS) is an endocrine disease closely related to several risk factors of cardiovascular disease. Obese women with PCOS show altered autonomic modulation. The results of studies investigating cardiac autonomic functions of normal-weight women with PCOS are conflicting. The aim of the study was to assess the reactivity of cardiac sympathovagal balance in normal-weight women with PCOS by heart rate variability analysis. METHODS: We examined the heart rate variability in 60 normal-weight women with PCOS and compared them with that in 60 age-matched healthy women having a similar metabolic profile. Time and frequency domain parameters of heart rate variability were analyzed based on 5-min-long continuous electrocardiography recordings for the following 3 periods: (1) during rest in supine position, (2) during controlled breathing, and (3) during isometric handgrip exercise. RESULTS: Time and frequency domain parameters of heart rate variability for the 3 periods assessed were similar in the two groups. Although modified Ferriman-Gallwey score and serum testosterone and luteinizing hormone levels were significantly higher in women with PCOS, homeostatic model assessment-insulin resistance (HOMA-IR) was not different the between the PCOS and control groups. There were no significant correlations between serum testosterone levels and heart rate variability parameters among the study population. CONCLUSION: The findings of this study suggest that the reactivity of cardiac sympathovagal balance is not altered in normal-weight women with PCOS having a normal HOMA-IR.

Which Coronary Lesions Are More Prone to Cause Acute Myocardial Infarction? / Quais Lesões Coronarianas São Mais Propensas a Causar Infarto Agudo do Miocárdio?

Abstract Background: According to common belief, most myocardial infarctions (MIs) are due to the rupture of nonsevere, vulnerable plaques with < 70% obstruction. Data from recent trials challenge this belief, suggesting that the risk of coronary occlusion is, in fact, much higher after severe stenosis. The aim of this study was to investigate whether or not acute ST-elevation MIs result from high-grade stenoses by evaluating the presence of coronary collateral circulation (CCC). Methods: We retrospectively included 207 consecutive patients who had undergone primary percutaneous coronary intervention for acute ST-elevation MI. Collateral blood flow distal to the culprit lesion was assessed by two investigators using the Rentrop scoring system. Results: Out of the 207 patients included in the study, 153 (73.9%) had coronary collateral vessels (Rentrop 1-3). The Rentrop scores were 0, 1, 2, and 3 in 54 (26.1%), 50 (24.2%), 51 (24.6%), and 52 (25.1%) patients, respectively. Triglycerides, mean platelet volume (MPV), white cell (WBC) count, and neutrophil count were significantly lower in the group with good collateral vessels (p = 0.013, p = 0.002, p = 0.003, and p = 0.021, respectively). Conclusion: More than 70% of the patients with acute MI had CCC with Rentrop scores of 1-3 during primary coronary angiography. This shows that most cases of acute MI in our study originated from underlying high-grade stenoses, challenging the common believe. Higher serum triglycerides levels, greater MPV, and increased WBC and neutrophil counts were independently associated with impaired development of collateral vessels.

Resumo Fundamento: Há uma crença geral de que a maioria dos infartos agudos do miocárdio (IAM) ocorrem devido à ruptura de placas vulneráveis, não graves, com obstrução < 70%. Dados de ensaios recentes desafiam esta crença, sugerindo que o risco de oclusão coronariana é, na realidade, muito maior após estenose grave. O objetivo deste estudo foi investigar se a presença ou não de IAM com supradesnível do segmento ST resulta de estenoses de alto grau através da avaliação da presença de circulação colateral coronariana (CCC). Métodos: Nós incluímos retrospectivamente 207 pacientes consecutivos submetidos à intervenção coronariana percutânea primária devido à ocorrência de IAM com supradesnível do segmento ST. O fluxo sanguíneo colateral distal à lesão culpada foi avaliado por dois investigadores com utilização do sistema de escores de Rentrop. Resultados: Dos 207 pacientes incluídos no estudo, 153 (73,9%) apresentavam vasos coronarianos colaterais (Rentrop 1-3). Os escores Rentrop foram de 0, 1, 2 e 3 em 54 (26,1%), 50 (24,2%), 51 (24,6%) e 52 (25,1%) pacientes, respectivamente. Triglicérides, volume plaquetário médio (VPM), contagem de células brancas (CCB) e contagem de neutrófilos estiveram significativamente mais baixos no grupo com bons vasos colaterais (p = 0,013, p = 0,002, p = 0,003 e p = 0,021, respectivamente). Conclusão: Mais de 70% dos pacientes com IAM apresentaram CCC com escores de Rentrop de 1-3 durante angiografia coronariana primária. Isto demonstra que a maioria dos casos de IAM em nosso estudo originou a partir de estenoses subjacentes de alto grau, contrariamente à sabedoria comum. Níveis séricos mais elevados de triglicérides, maior VPM e elevação na CCB e na contagem de neutrófilos estiveram independentemente associados com comprometimento no desenvolvimento de vasos colaterais.

Which Coronary Lesions Are More Prone to Cause Acute Myocardial Infarction?

BACKGROUND:: According to common belief, most myocardial infarctions (MIs) are due to the rupture of nonsevere, vulnerable plaques with < 70% obstruction. Data from recent trials challenge this belief, suggesting that the risk of coronary occlusion is, in fact, much higher after severe stenosis. The aim of this study was to investigate whether or not acute ST-elevation MIs result from high-grade stenoses by evaluating the presence of coronary collateral circulation (CCC). METHODS:: We retrospectively included 207 consecutive patients who had undergone primary percutaneous coronary intervention for acute ST-elevation MI. Collateral blood flow distal to the culprit lesion was assessed by two investigators using the Rentrop scoring system. RESULTS:: Out of the 207 patients included in the study, 153 (73.9%) had coronary collateral vessels (Rentrop 1-3). The Rentrop scores were 0, 1, 2, and 3 in 54 (26.1%), 50 (24.2%), 51 (24.6%), and 52 (25.1%) patients, respectively. Triglycerides, mean platelet volume (MPV), white cell (WBC) count, and neutrophil count were significantly lower in the group with good collateral vessels (p = 0.013, p = 0.002, p = 0.003, and p = 0.021, respectively). CONCLUSION:: More than 70% of the patients with acute MI had CCC with Rentrop scores of 1-3 during primary coronary angiography. This shows that most cases of acute MI in our study originated from underlying high-grade stenoses, challenging the common believe. Higher serum triglycerides levels, greater MPV, and increased WBC and neutrophil counts were independently associated with impaired development of collateral vessels. FUNDAMENTO:: Há uma crença geral de que a maioria dos infartos agudos do miocárdio (IAM) ocorrem devido à ruptura de placas vulneráveis, não graves, com obstrução < 70%. Dados de ensaios recentes desafiam esta crença, sugerindo que o risco de oclusão coronariana é, na realidade, muito maior após estenose grave. O objetivo deste estudo foi investigar se a presença ou não de IAM com supradesnível do segmento ST resulta de estenoses de alto grau através da avaliação da presença de circulação colateral coronariana (CCC). MÉTODOS:: Nós incluímos retrospectivamente 207 pacientes consecutivos submetidos à intervenção coronariana percutânea primária devido à ocorrência de IAM com supradesnível do segmento ST. O fluxo sanguíneo colateral distal à lesão culpada foi avaliado por dois investigadores com utilização do sistema de escores de Rentrop. RESULTADOS:: Dos 207 pacientes incluídos no estudo, 153 (73,9%) apresentavam vasos coronarianos colaterais (Rentrop 1-3). Os escores Rentrop foram de 0, 1, 2 e 3 em 54 (26,1%), 50 (24,2%), 51 (24,6%) e 52 (25,1%) pacientes, respectivamente. Triglicérides, volume plaquetário médio (VPM), contagem de células brancas (CCB) e contagem de neutrófilos estiveram significativamente mais baixos no grupo com bons vasos colaterais (p = 0,013, p = 0,002, p = 0,003 e p = 0,021, respectivamente). CONCLUSÃO:: Mais de 70% dos pacientes com IAM apresentaram CCC com escores de Rentrop de 1-3 durante angiografia coronariana primária. Isto demonstra que a maioria dos casos de IAM em nosso estudo originou a partir de estenoses subjacentes de alto grau, contrariamente à sabedoria comum. Níveis séricos mais elevados de triglicérides, maior VPM e elevação na CCB e na contagem de neutrófilos estiveram independentemente associados com comprometimento no desenvolvimento de vasos colaterais.

Successful thrombolytic treatment of a mobile thrombus on atrial septal defect occluder device.

This case report presents a case with septal occluder device thrombosis which was successfully treated with low dose longer duration of thrombolytic application. Our case showed that the thrombolytic strategy with the lower dose and the longer duration might be a valuable alternative treatment option for the septal occluder thrombosis which is anticoagulation-resistant. This strategy might obviate the need for surgery.

The effects of air pollution and weather conditions on the incidence of acute myocardial infarction.

OBJECTIVE: In this retrospective study, we investigated the association between air pollution and weather conditions with the incidence of acute myocardial infarction (AMI) in the city of Kutahya. METHODS: A total of 402 patients who were admitted with acute ST segment elevation MI and non-ST segment elevation MI were included in the study in 1 year. Daily maximum, minimum, and mean ambient temperature and mean barometric pressure data were obtained from the Kutahya Meteorology Department. Daily air pollution data were obtained from the Web site of National Air Quality Observation Network (http://www.havaizleme.gov.tr). RESULTS: Increase in ambient air temperature in the day of MI and 2 days before the day of MI according to their control days was correlated with increase in number of MI cases. When we grouped the patients according to ages as 30-54, 55-65, and >65 years, we found that there was a relation between sulfur dioxide (SO2) and the occurrence of AMI for the age group of 30-54 for the same day (D0) (P<.017). The number of AMIs was the lowest in fall season, whereas the number of AMIs was the highest in winter season. CONCLUSION: There was no statistically significant association between the particulates with diameter b=10 µm, SO2 concentrations, air pressure, and the risk of AMI, but there was statistically significant relation between occurrence of MI and SO2 for the patients under age of 55 years. The number of AMIs was the lowest in fall season, whereas the number of AMIs was the highest in winter season.

Autonomic modulation in hypertension without hypertrophy.

OBJECTIVES: Cardiac autonomic modulation and baroreflex sensitivity are altered in individuals with essential hypertension. Hypertension is considered as a strong and independent risk factor for supraventricular and ventricular arrhythmias. The aim of the present study was to evaluate cardiac autonomic control and the arrhythmogenic risk by using 24-h heart rate variability (HRV) and heart rate turbulence (HRT) analysis in essential hypertension without left ventricular hypertrophy (LVH). METHODS: Fifty-eight newly diagnosed untreated hypertensive patients without LVH (mean age 51 ± 12 years, 26 women) and 56 adult, healthy volunteers (mean age 49 ± 12 years, 24 women) were included in the study. Subjects with secondary causes of hypertension or autonomic dysfunction were excluded. The diagnosis of hypertension was based on ambulatory blood pressure monitoring results. Time-domain HRV parameters and HRT parameters were calculated from 24-hour Holter recordings. RESULTS: Values of SDNN and SDANN in the hypertension group were significantly lower than in the control group (P < 0.01 and P < 0.01, respectively). At least one of the turbulence onset (TO) and turbulence slope (TS) values were found abnormal in 10 of 32 hypertensive patients and in 5 of 24 control individuals (P = 0.38). There was no significant difference between HRT parameters, TO and TS (P = 0.67 and P = 0.12, respectively). CONCLUSIONS: Sympathetic tone begins to increase in hypertension before LVH develops. However, the impact of this increase on HRT is not clear. There is a need for further research to investigate the impact of hypertension and LVH on HRT.

The usefulness of plateletcrit to predict cardiac syndrome X in patients with normal coronary angiogram.

INTRODUCTION: Cardiac syndrome X (CSX) is a clinical entity defined as the triad of typical angina pectoris on exercise, electrocardiographic or metabolic findings of ischemia and normal epicardial coronary arteries. Platelets, whose amount in the blood is indicated with plateletcrit (PCT), play an important role in inflammatory and thrombotic processes and the physiopathology of cardiovascular events. AIM: To investigate the association between cardiac syndrome X and PCT and platelet count. MATERIAL AND METHODS: A total of 113 patients with normal coronary angiogram were included in the study. Fifty patients with typical chest pain and evidence of myocardial ischemia in non-invasive tests formed the CSX patient group. The control group consisted of 63 age- and gender-matched patients with normal coronary arteries but without angina. RESULTS: The mean PCT value of the CSX group was significantly higher than that of the control group (0.22 ±0.06 vs. 0.19 ±0.04; respectively, p=0.03). Higher PCT was found to be associated with the presence of CSX in patients with normal coronary arteries by multivariate logistic regression analysis. CONCLUSIONS: We suggest that high PCT may predict the presence of cardiac syndrome X in patients with normal coronary arteries. The value of PCT appears additive to conventional expensive methods commonly used in CSX prediction.

The effect of zolmitriptan on cardiac autonomic modulation in patients with migraine: A double-blind, placebo-controlled, crossover study.

BACKGROUND: Triptans, which activate 5-hydroxytryptamine (5-HT)-1B/1D receptors in cerebral arteries, are very effective in aborting attacks of migraine. Although activation of 5-HT-1B/1D receptors diminishes the secretion of noradrenaline from cardiac sympathetic nerves, some studies report that they may cause chest discomfort, myocardial infarction and arrhythmias due to coronary vasospasm. The effect of zolmitriptan on cardiac autonomic modulation has not been evaluated in migraineurs. SUBJECTS AND METHODS: Ten patients with migraine (nine women, mean age 33 ± 4 years) were crossover randomized to 2.5 mg zolmitriptan or identical placebo at least 5 days apart. Both time domain parameters (the mean R-R interval, the standard deviation of RR interval [SDNN], and the root mean square of successive R-R interval differences) and frequency domain parameters (low frequency [LF], high frequency [HF], and LF/HF ratio) of heart rate variability (HRV) were obtained during supine position, controlled respiration and handgrip exercise before and 2 h after zolmitriptan or placebo administration. RESULTS: Baseline HRV parameters were similar for each occasion. Single dose zolmitriptan administration did not affect both time and frequency domain HRV parameters compared with the placebo. CONCLUSIONS: A single dose, 2.5 mg oral zolmitriptan administration did not change sympathetic and parasympathetic reactivity and sympathovagal balance in migraineurs.

Arrhythmogenic right ventricular cardiomyopathy in monozygotic twin sisters, and persistent left superior vena cava in one complicating implantation of ICD.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiomyopathy characterized histologically by fibro-fatty replacement of heart muscle, and clinically by ventricular arrhythmias and right ventricular dysfunction. This report presents monozygotic twins with ARVC, suggesting a genetic abnormality as the most probable cause.

Time-to-reperfusion in STEMI undergoing interhospital transfer using smartphone and WhatsApp messenger.

OBJECTIVE: The objective of this study is to assess the efficacy of WhatsApp application as a communication method among the emergency physician (EP) in a rural hospital without percutaneous coronary intervention (PCI) capability and the interventional cardiologist at a tertiary PCI center. BACKGROUND: Current guidelines recommend that patients with ST-segment elevation myocardial infarction (STEMI) receive primary PCI within 90 minutes. This door-to-balloon (D2B) time has been difficult to achieve in rural STEMI. METHODS AND RESULTS: We evaluated 108 patients with STEMI in a rural hospital with emergency department but without PCI capability to determine the impact of WhatsApp triage and activation of the cardiac catheterization laboratory on D2B time. The images were obtained from cases of suspected STEMI using the smartphones by the EP and were sent to the interventional cardiologist via the WhatsApp application (group 1, n=53). The control group included concurrently treated patients with STEMI during the same period but not receiving triage (group 2, n=55). The D2B time was significantly shorter in the intervention group (109±31 vs 130±46 minutes, P<.001) with significant reduction in false STEMI rate as well. CONCLUSION: This study demonstrates that use of WhatsApp triage with activation of the cardiac catheterization laboratory was associated with shorter D2B time and results in a greater proportion of patients achieving guideline recommendations. The method is cheap, quick, and easy to operate.

Relationship between platelet-to-lymphocyte ratio and coronary slow flow.

OBJECTIVE: The coronary slow flow phenomenon (CSFP), which is characterized by delayed distal vessel opacification in the absence of significant epicardial coronary disease, is an angiographic finding. The aim of this study is to investigate the association between platelet-to-lymphocyte ratio (PLR) and coronary blood flow rate. METHODS: This is a retrospective observational study. It was based on two medical centers. A total of 197 patients undergoing coronary angiography were included in the study, 95 of whom were patients with coronary slow flow without stenosis in coronary angiography and 102 of whom had normal coronary arteries and normal flow. RESULTS: The PLR was higher in the coronary slow flow group compared with the control groups (p=0.001). In the correlation analysis, PLR showed a significant correlation with left anterior descending (LAD) artery thrombolysis in myocardial infarction (TIMI) frame count. After multiple logistic regression, high levels of PLR were independently associated with coronary slow flow, together with hemoglobin. CONCLUSION: PLR was higher in patients with CSFP, and we also showed that PLR was significantly and independently associated with CSFP.