Epicardial fat thickness assessment by multi-slice computed tomography for predicting cardiac outcomes in patients undergoing transcatheter aortic valve implantation.

INTRODUCTION: Chronic inflammation promotes aortic valve calcification. It is known that epicardial fat is a source of inflammation. The aim of this study was to investigate the relationship between epicardial fat thickness, cardiac conduction disorders and outcomes in patients undergoing transcatheter aortic valve implantation (TAVI). METHODS: During a three-year period, 45 patients with severe aortic stenosis who underwent TAVI were recruited to the study. Data were collected retrospectively. Epicardial fat was defined as the adipose tissue between the epicardium and the visceral pericardium. Mean epicardial fat thickness was determined by multi-slice computed tomography, which was performed before the procedure. RESULTS: The average thickness of epicardial fat was 13.06 ± 3.29 mm. This study failed to reveal a significant correlation between epicardial fat thickness and post-procedural left bundle branch block, right bundle branch block, paravalvular aortic regurgitation and pacemaker implantation rates (p > 0.05). CONCLUSIONS: The results of this study failed to show a significant relationship between epicardial fat thickness, cardiac conduction disorders and outcomes, however further studies with larger sample numbers are required to explore the relationship.

CHA2DS2-VASc Score Predicts In-Hospital and Long-Term Clinical Outcomes in Patients With ST-Segment Elevation Myocardial Infarction Who Were Undergoing Primary Percutaneous Coronary Intervention.

CHA2DS2-VASc score includes similar risk factors for coronary artery disease. We hypothesized that admission CHA2DS2-VASc score might be predictive of adverse clinical outcomes for patients with ST-segment elevation myocardial infarction (STEMI) who were undergoing primary percutaneous coronary intervention. A total of 647 patients with STEMI enrolled in this study. The study population was divided into 2 groups according to their admission CHA2DS2-VASc score. The low group (n = 521) was defined as CHA2DS2-VASc score ≤2, and the high group (n = 126) was defined as CHA2DS2-VASc score >2. Patients in the high group had significantly higher incidence of in-hospital cardiovascular mortality (8.7% vs 1.9%; P < .001). Long-term mortality was significantly frequent in the high group (13.4% vs 3.6%, P < .001). Hypertension, admission CHA2DS2-VASc score, and Killip class >1 were independent predictors of long-term mortality. Admission CHA2DS2-VASc score >2 was identified as an effective cutoff point for long-term mortality (area under curve = 0.821; 95% confidence interval: 0.76-0.89; P < .001). CHA2DS2-VASc score is a simple, very useful, easily remembered bedside score for predicting in-hospital and long-term adverse clinical outcomes in STEMI.

Safety of Early Discharge After Primary Percutaneous Coronary Intervention.

In contrast to ST-elevation myocardial infarction treatment, there is no clear definition for when and which patient to discharge. Our study's main goal was to test the hypothesis that an early discharge strategy (within 48 to 56 hours) in patients with successful primary percutaneous coronary intervention (PPCI) is as safe as in patients who stay longer. The Early Discharge after Primary Percutaneous Coronary Intervention trial was designed in a prospective, randomized, multicenter fashion and registered with http://clinicaltrials.gov (NCT01860079). Of 900 patients with ST-elevation myocardial infarction, the study randomized 769 eligible patients to the early or the standard discharge group. The study's primary outcomes were all-cause mortality and readmission at 30 days. We considered assessment of functional status and health-related quality of life to be secondary outcomes. The early discharge group had significantly shorter length of hospital stay compared with the standard discharge group (45.99 ± 9.12 vs 114.87 ± 63.53 hours; p <0.0001). Neither all-cause mortality nor readmissions were different between the 2 study groups (p = 0.684 and p = 0.061, respectively). Quality-of-life measures were not statistically different between the 2 study groups. Our study reveals that discharge within 48 to 56 hours after successful PPCI is feasible, safe, and does not increase the 30-day readmission rate. Moreover, the patients perceived health status at 30 days did not differ with early discharge.

The Impact of Admission Serum Creatinine Derived Estimated Glomerular Filtration Rate on Major Adverse Cardiac Events in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention.

BACKGROUND: The impact of Cockroft-Gault (C-G) derived estimated glomerular filtration rate (eGFR) on mortality and major adverse cardiac events (MACEs) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) was assessed. METHODS: A total of 884 patients were classified into four categories according to admission creatine derived eGFR: < 60, 60 - < 90, 90 - < 120, and ≥ 120 mL/min/1.73 m(2). RESULTS: In-hospital and long-term MACEs were significantly higher in eGFR < 60 mL/min/1.73 m(2) subgroup (P < 0.001 and P = 0.028). Multivariate analysis demonstrated 7.78-fold (95% CI: 0.91 - 66.8) higher mortality risk in eGFR < 60 mL/min/1.73 m(2) subgroup. CONCLUSION: As an easily applicable bedside method, C-G derived eGFR could be important for prediction of in-hospital and long-term mortality and MACE in STEMI patients undergoing primary PCI.

Admission Glucose Level Predicts In-hospital Mortality in Patients with Acute Pulmonary Embolism Who Were Treated with Thrombolytic Therapy.

BACKGROUND: Elevated admission serum glucose level is associated with unfavourable clinical outcomes in various clinical conditions. The aim of this study was to investigate the relationship between admission glucose levels and in-hospital and long-term adverse clinical outcomes in patients with pulmonary embolism (PE) treated with thrombolytic therapy. METHODS: A total of 183 consecutive confirmed acute PE patients (98 female and 85 male; mean age 61.9 ± 15.7 years) who were treated with thrombolytic therapy enrolled in this study. The study population was categorised into four quartiles according to admission serum glucose levels (group I: glucose ≤115 mg/dl; group II: glucose >115-141 mg/dl; group III: glucose >141-195 mg/dl; and group IV: glucose ≥196 mg/dl). RESULTS: In-hospital mortality was significantly higher in group IV (28.8 %) compared to group III (15.2 %), group II (6.6 %), and group I (2.1 %) (p < 0.001). In multivariate analysis, admission glucose level (OR 1.013, 95 % CI 1.004-1.021, p = 0.004) and admission anaemia (OR 0.602, 95 % CI 0.380-0.955, p = 0.03) were independent predictors of in-hospital mortality. The mean follow-up period was 34 months. During long-term follow-up, all-cause mortality, recurrent PE, major and minor bleeding were similar among the four groups. CONCLUSION: Admission glucose level is a simple, inexpensive, easily available, and effective laboratory parameter for predicting in-hospital mortality in patients with PE.

Sublingual vs. Oral Captopril in Hypertensive Crisis.

BACKGROUND: There are confusing data in literature regarding oral and sublingual captopril effects over blood pressure (BP) decrease. OBJECTIVES: In our study we compared oral and sublingual captopril effectiveness over BP decrease in patients admitted to our Emergency Department with hypertensive urgency. METHODS: Our study was conducted from January 2012 to January 2013 in patients with hypertensive urgency. In this cross-sectional study after two initial BP measurements, patients were identified as eligible for the study. An initial electrocardiogram was obtained and blood samples were drawn. A total of 212 patients were accepted as eligible for the study, and 25 mg of captopril was randomly given orally or sublingually; BP was measured at 10, 30, and 60 min. We selected the patients to the groups consecutively. A 25% reduction of initial BP 1 h after initiation of the treatment was accepted as an accomplishment. A second 25 mg of captopril was given if the target of 25% reduction of BP was not reached after the first tablet. Intravenous drugs were administered to the patients resistant to the captopril and these patients were excluded from the study. RESULTS: The 10-min systolic BP (SBP), diastolic BP, and mean BP (MBP) decrease was more prominent in the sublingual captopril group (p < 0.001). This decrease was statistically significant in the SBP and MBP at 30 min (p < 0.001), and no statistical difference was recorded at 60 min (p > 0.05). CONCLUSIONS: In our study, sublingual captopril was found to decrease BP more efficiently in the first 30 min, but this difference equalized at 60 min.

Admission serum potassium level is associated with in-hospital and long-term mortality in ST-elevation myocardial infarction.

OBJECTIVE: Current guidelines recommend a serum potassium (sK) level of 4.0-5.0 mmol/L in acute myocardial infarction patients. Recent trials have demonstrated an increased mortality rate with an sK level of>4.5 mmol/L. The aim of this study was to figure out the relation between admission sK level and in-hospital and long-term mortality and ventricular arrhythmias. METHODS: Retrospectively, 611 patients with ST-elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention were recruited. Admission sK levels were categorized accordingly: <3.5, 3.5-<4, 4-<4.5, 4.5-<5, and ≥5 mmol/L. RESULTS: The lowest in-hospital and long-term mortality occurred in patients with sK levels of 3.5 to <4 mmol/L. The long-term mortality risk increased for admission sK levels of >4.5 mmol/L [odds ratio (OR), 1.58; 95% confidence interval (CI) 0.42-5.9 and OR, 2.27; 95% CI 0.44-11.5 for sK levels of 4.5-<5 mmol/L and ≥5 mmol/L, respectively]. At sK levels <3 mmol/L and ≥5 mmol/L, the incidence of ventricular arrhythmias was higher (p=0.019). CONCLUSION: Admission sK level of >4.5 mmol/L was associated with increased long-term mortality in STEMI. A significant relation was found between sK level of <3 mmol/L and ≥5 mmol/L and ventricular arrhythmias.

Relationship between Neutrophil-to-Lymphocyte Ratio and Left Ventricular Free Wall Rupture in Acute Myocardial Infarction.

OBJECTIVES: This study aimed to evaluate the relationship between the neutrophil-to-lymphocyte (N/L) ratio and left ventricular free wall rupture (LVFWR) in patients with ST elevation myocardial infarction (STEMI). Previous studies showed a correlation between increased levels of inflammatory markers and adverse cardiovascular events. The role of inflammation markers, particularly the N/L ratio, in mechanical complications after myocardial infarction has not been studied. METHODS: Retrospectively, we compared the N/L ratio values of 23 patients with STEMI complicated by LVFWR with 214 STEMI patients without this complication. The diagnosis of rupture was confirmed by echocardiography in each case. RESULTS: Neutrophil counts [median 8.5 × 103/µl, interquartile range (IQR) 6.4, vs. 7.8 × 103/µl, IQR 4.7, p = 0.02] and the N/L ratio (5.66, IQR 4.17, vs. 4.1, IQR 3.93, p = 0.01) were significantly higher in the LVFWR group. In receiver operating characteristic analysis, an N/L ratio above 3.7 predicted LVFWR with a sensitivity of 82.6% and a specificity of 46.9% (area under the curve = 0.654, p = 0.016). In multivariate regression analysis, age, hypertension, increased creatinine levels and increased N/L ratio (odds ratio = 1.61, 95% confidence interval = 1.15-2.23, p = 0.01) were found to be independent predictors of LVFWR. CONCLUSIONS: In our study, the N/L ratio was found to be independently correlated with the risk of LVFWR. © 2015 S. Karger AG, Basel.

ST-segment elevation of right precordial lead (V4 R) is associated with multivessel disease and increased in-hospital mortality in acute anterior myocardial infarction patients.

BACKGROUND: ST segment elevation of chest lead V4 R is associated with worse prognosis in acute inferior ST-elevation myocardial infarction (STEMI). This study tried to determine the relationship between ST elevation in the right precordial lead V4 R and acute anterior STEMI. METHODS: Prospective study of 144 consecutive anterior STEMI patients: all had 15-lead ECG recordings (12 conventional leads and V3 R-V5 R) obtained. Patients were classified into two groups on the basis of presence (Group I, 50 patients) or absence (Group II, 94 patients) of ST-segment elevation ≥0.5 mm in lead V4 R. RESULTS: Multivessel involvement was significantly higher in Group I compared with Group II (54% and 23% respectively, P < 0.001). Major adverse cardiac events and in-hospital mortality was also significantly higher for those in Group I (P < 0.02 for both). A significant correlation was found between in-hospital mortality and those in Group I (P = 0.03, OR: 6.27, CI: 1.22-32.3). There was an independent relationship between in-hospital mortality and V4 R-ST elevation (P = 0.03, OR: 11.64, CI: 1.3-27.4). CONCLUSION: ST segment elevation in chest lead V4 R is associated with multivessel disease and increased in-hospital mortality in patients with anterior STEMI that had undergone primary percutaneous coronary intervention to the left anterior descending artery.

The reliability of computed tomography-derived SYNTAX score measurement.

The Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score (SS) was developed for evaluation of coronary artery disease complexity. We aimed to compare the SS calculated by conventional coronary angiography (CAG) and computed tomography angiography (CTA). Retrospectively, 107 patients were recruited (mean age 55.9 ± 12.4 years). The SS measured by conventional CAG was divided into 3 groups (group 1 SS ≤ 22, group 2 SS > 22 to <32, and group 3 SS ≥ 32). The SS calculated by both methods has a high correlation (r = .972 and P < .001). The κ analysis showed a substantial agreement between both imaging modalities. Computed tomography angiography highly predicted conventional CAG lesions (area under curve 0.96, 95% confidence interval 0.92-0.99, and P < .001). The SS measured by CTA is highly correlated with conventional CAG. Therefore, we propose that prior to coronary revascularization, CTA-derived SS could be used for risk stratification.

Combination of hemoglobin and left ventricular ejection fraction as a new predictor of contrast induced nephropathy in patients with non-ST elevation myocardial infarction.

BACKGROUND: Hemoglobin concentration (Hb) and left ventricular ejection fraction (EF) are known predictors of contrast induced nephropathy (CIN). We hypothesized that combination of Hb concentration and left ventricular EF is superior to either variable alone in predicting contrast induced nephropathy in patients with acute coronary syndrome (ACS). MATERIAL AND METHODS: Consecutive patients with ACS were prospectively enrolled. Patients considered for invasive strategy were included. Baseline creatinine levels were detected on admission and 24, 48 and 72 hours after coronary intervention. 25% or 0,5 umol/L increase in creatinine level was considered as CIN. RESULTS: 268 patients with ACS (mean age 58±11 years, 77% male) were enrolled. Contrast induced nephropathy was observed in 26 (9.7%) of patients. Baseline creatinine concentration, left ventricular EF, and Hemoglobin was significantly different between two groups. Contrast volume to estimated glomerular filtration rate ratio (OR: 1.310, 95% CI: 1.077-1.593, p=0.007) and the combination of Hb and left ventricular EF (OR: 0.996, 95% CI: 0.994-0.998, p=0.001) were found to be independent predictors for CIN. Hb × LVEF ≤690 had 85% sensitivity and 57% specificity to predict CIN (area under curve: 0.724, 95% CI: 0.625-0.824, p<0.001). In addition, Hb × LVEF ≤690 had a negative predictive value of 97% in our analysis CONCLUSIONS: The combination of Hb and left ventricular EF is better than either variable alone at predicting CIN in patients with ACS that undergone percutaneous coronary intervention. The prediction was independent of baseline renal function and volume of contrast agent.

Neutrophil-to-lymphocyte ratio as a prognostic marker in infective endocarditis: in-hospital and long-term clinical results.

BACKGROUND AND AIM OF THE STUDY: The neutrophil-to-lymphocyte ratio (NLR) is an independent predictor of poor prognosis in different clinical conditions such as infectious and cardiovascular diseases. It was hypothesized that a patient's admission NLR would be predictive of an adverse clinical outcome in cases of infective endocarditis (IE). METHODS: A total of 171 patients with IE was enrolled retrospectively, and allocated to two tertiles based on admission NLR values. The high-NLR group (n = 76) was defined as having an NLR value in the third tertile (> 5.46), and the low-NLR group (n = 95) as having a value in the lower two tertiles (≤ 5.46). RESULTS: Patients in the high-NLR group had a significantly higher incidence of in-hospital mortality than the low-NLR group (39.4% versus 18.9%, p = 0.003). A high NLR was found to be an independent predictor of in-hospital mortality (odds ratio 2.53, 95% confidence interval 1.19-5.3; p = 0.01). The mean follow up was 25.5 months, and long-term follow up mortality was similar in both groups (12.9% versus 19.5%; p = 0.33). CONCLUSION: A high NLR at admission is associated with increased in-hospital mortality in patients with IE. During the long-term follow up, NLR showed no predictive indication of mortality.

The relationship between γ-glutamyl transferase levels and the clinical outcomes in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

OBJECTIVES: Serum γ-glutamyl transferase (GGT) activity has been shown to be related to the development of atherosclerosis and cardiovascular events. The aim of this study was to evaluate the prognostic value of GGT in patients with ST-segment elevation myocardial infarction (STEMI) undergoing a primary percutaneous coronary intervention (PCI). PATIENTS AND METHODS: A total of 683 consecutive patients with STEMI who underwent primary PCI were evaluated. The study population was divided into tertiles on the basis of admission GGT values. A high GGT (n=221) was defined as a value in the upper third tertile (GGT>37) and a low GGT (n=462) was defined as any value in the lower two tertiles (GGT≤37). The mean follow-up time was 29 months. RESULTS: The in-hospital mortality rate was significantly higher in patients in the high GGT group (7.2 vs. 1.7%, P<0.001), as was the rate of adverse outcomes in patients with high GGT levels. In multivariate analyses, a significant association was found between high GGT levels and adjusted risk of in-hospital cardiovascular mortality (odds ratio=8.6, 95% confidence interval: 2.3-32.4, P=0.001). In a receiver operating characteristic curve analysis, a GGT value greater than 37 was identified as an effective cutoff point in STEMI for in-hospital cardiovascular mortality (area under curve=0.71, 95% confidence interval: 0.59-0.82, P<0.001). There were no differences in the long-term adverse outcome rates between the two groups. CONCLUSION: GGT is a readily available clinical laboratory value associated with in-hospital adverse outcomes in patients with STEMI who undergo primary PCI. However, there was no association with long-term mortality.