Predictors of Long-Term Mortality in Patients with Stable Angina Pectoris and Coronary Slow Flow.

Background and Objectives: Coronary slow flow (CSF) is an angiographic phenomenon characterized by the slow progression of an injected contrast agent during diagnostic coronary angiography in the absence of significant stenosis. Although CSF is a common angiographic finding, the long-term outcomes and mortality rates are still unknown. This study aimed to investigate the underlying causes of mortality over a 10-year period in patients diagnosed with stable angina pectoris (SAP) and CSF. Materials and Methods: This study included patients with SAP who underwent coronary angiography from 1 January 2012 to 31 December 2012. All patients displayed CSF despite having angiographically normal coronary arteries. Hypertension (HT), diabetes mellitus (DM), hyperlipidaemia, medication compliance, comorbidities, and laboratory data were recorded at the time of angiography. Thrombolysis in myocardial infarction (TIMI) frame count (TFC) was calculated for each patient. The cardiovascular (CV) and non-CV causes of long-term mortality were assessed. Results: A total of 137 patients with CSF (93 males; mean age: 52.2 ± 9.36 years) were included in this study. Twenty-one patients (15.3%) died within 10 years of follow-up. Nine (7.2%) and 12 (9.4%) patients died of non-CV and CV causes, respectively. Total mortality in patients with CSF was associated with age, HT, discontinuation of medications, and high-density lipoprotein cholesterol (HDL-C) levels. The mean TFC was associated with CV mortality. Conclusion: Patients with CSF exhibited a notable increase in cardiovascular-related and overall mortality rates after 10 years of follow-up. HT, discontinuation of medications, HDL-C levels, and mean TFC were associated with mortality in patients with CSF.

Value of the neutrophil-to-lymphocyte ratio in predicting left ventricular recovery in patients with peripartum cardiomyopathy.

OBJECTIVE: The aim of this study was to assess the value of the neutrophil-to-lymphocyte ratio (NLR) in predicting left ventricular (LV) recovery in patients with peripartum cardiomyopathy (PPCM). METHODS: Patients with PPCM (n = 40), who were admitted to our tertiary reference hospital between 2007 and 2015 were retrospectively analyzed. All patients were followed-up for at least 12 months after the diagnosis. All patients had standard echocardiographic examination at baseline and the last follow-up visit. Recovery of LV function was defined as the presence of LV ejection fraction (EF) >45%. Data on blood parameters were also collected at baseline. Univariate and multivariate analysis were used to assess the significant predictive variables for persistent LV systolic dysfunction. RESULTS: Of the patients 21 (52.5%) did not recover LV function at the last follow-up visit (nonrecovery group), while 19 of the patients (47.5%) exhibited LV recovery (recovery group). The LV EF and fractional shortening (FS) were significantly lower in the nonrecovery group. The baseline LV end-diastolic diameter, LV end-systolic diameter (LVESD) and systolic pulmonary arterial pressure were significantly increased in the nonrecovery group. The NLR, C­reactive protein and troponin levels were significantly higher in the nonrecovery group. In multivariate logistic regression analysis only NLR and LVESD were identified as independent predictors of persistent LV systolic dysfunction in patients with PPCM (p = 0.020 and p = 0.009 respectively). CONCLUSION: Elevated NLR and increased LVESD were independent prognostic factors in predicting persistent LV dysfunction in patients with PPCM. The NLR might assist in identifying high risk patients with PPCM.

Severity of periodontitis in patients with isolated coronary artery ectasia.

The concept that coronary artery ectasia (CAE) is an inflammatory-related disease has been increasingly recognized. Periodontitis induced low-grade chronic systemic inflammation has been shown to be associated with cardiovascular diseases. The aim of the present study was to evaluate the association between periodontitis and CAE.Thirty-two patients with isolated CAE, and 28 age, sex and smoking status-matched subjects with normal coronary arteries (NCA) underwent full dental examinations. Periodontal disease was evaluated using the following clinical parameters; number of remaining teeth, plaque index (PI), gingival index (GI), bleeding on probing (BOP), and pocket depth (PD).Cases and controls did not differ according to their baseline characteristics and prevalence of traditional cardiovascular risk factors. Patients with isolated CAE had higher periodontal indices when compared to subjects with NCA (PD: 3.6 ± 1.26 mm versus 2.3 ± 0.79 mm; GI: 2.29 ± 0.86 versus 1.43 ± 1.19; BOP (%): 52.18 ± 20.1 versus 27.8 ± 10.9, P < 0.001, P < 0.05 and P < 0.05, respectively). Moreover, in multivariate analysis higher values for PD were found to be significant predictors for the likelihood of having coronary ectasia.The results of the present study demonstrate for the first time that there is an association between periodontitis and isolated CAE.

Successful primary percutaneous coronary intervention in a centenarian patient with acute myocardial infarction.

A 104-year-old male patient was admitted to the emergency department with chest pain. An electrocardiogram showed ST-segment elevation in the anterior leads. He was immediately taken to the catheterisation laboratory for emergency angiography, which showed thrombotic stenosis at the proximal portion of the left anterior descending (LAD) artery. After intervention on the LAD lesion, successful balloon angioplasty with stenting was performed. Here, we report a case of successful primary percutaneous coronary intervention (PCI) in a centenarian patient with acute myocardial infarction. There are few clinical data on centenarian patients with acute myocardial infarction undergoing primary PCI. To the best of best our knowledge, this case is the first reported in the literature where primary PCI was performed on a centenarian patient.

Is left ventricular diastolic dysfunction independent from presence of hypertension in metabolic syndrome? An echocardiographic study.

BACKGROUND: It has been shown that left ventricular diastolic dysfunction (LVDD) develops in patients with metabolic syndrome (MetS). However, there is not sufficient evidence in the literature to determine whether this condition is due to increase in blood pressure, which is frequently encountered in MetS. The purpose of this study was to test the hypothesis whether LVDD in MetS is independent from the presence of hypertension. METHODS: A total of 60 patients diagnosed with MetS and 30 healthy people, who were age- and gender-matched with the patient group, were included in the study as the control group. In the study group, 30 of the patients were normotensive whereas the other 30 had hypertension. Conventional echocardiographic examinations and tissue Doppler imaging were performed besides measurements of demographic and biochemical parameters. RESULTS: In the hypertensive MetS group, early diastolic filling flow (E), early diastolic mitral annular velocity (E'), and E/A ratio were significantly lower compared to the control group. Late diastolic filling flow (A), deceleration time (DT), late diastolic mitral annular velocity (A'), and E/E' ratio were higher in the hypertensive MetS group than the control group. In the normotensive MetS group, E, E', and E/A ratio were also lower compared to the control group whereas DT, A', and E/E' ratio were higher. CONCLUSION: These findings support the idea that LVDD may develop in patients with MetS even in the absence of hypertension. In addition, co-existence of hypertension with MetS contributes to further worsening of diastolic functions.

Echocardiographic assessment of right ventricular function before and after surgery in patients with pectus excavatum and right ventricular compression.

BACKGROUND: We aimed to evaluate the effect of surgical repair on right ventricular (RV) function in patients with pectus excavatum (PE) and RV compression by Doppler echocardiography. MATERIALS AND METHODS: Twenty-three patients who were admitted to our hospital for surgical correction of PE between 2009 and 2012 were included in the study. After transthoracic echocardiographic evaluation, 16 patients with RV compression were enrolled. All patients were males (100%) with a mean age of 20.5 ± 5.6 years. Transthoracic echocardiography was repeated 1 month after surgery. Echocardiographic evaluation included the assessment of RV diastolic diameter, tricuspid annular plane systolic excursion (TAPSE), pulsed tissue Doppler systolic velocity (S'), RV isovolumic acceleration (RV IVA), systolic pulmonary artery pressure, left ventricular (LV) ejection fraction, and myocardial performance indexes of both the right and the left ventricles (Tei index). RESULTS: Following the surgery, the RV end-diastolic diameter, TAPSE, S', and RV IVA were found to be significantly increased in patients with PE. In addition, RV and LV Tei index significantly improved after surgical correction. CONCLUSIONS: RV function significantly improved after corrective surgery. Quantitative echocardiographic examination provides accurate estimation when deciding for corrective surgery and also should be used in the assessment of postoperative improvement.

Oxidative stress and severity of coronary artery disease in young smokers with acute myocardial infarction.

BACKGROUND: Cigarette smoking increases the oxidative stress mediated vascular dysfunction in young adults. We aimed to investigate the relation between the oxidative stress indices and coronary artery disease (CAD) severity in young patients presenting with acute myocardial infarction (AMI). METHODS: Young patients (aged 〈 35 years) who were admitted consecutively to our hospital with a diagnosis of AMI were included in the study. Age matched healthy subjects were selected as controls. Oxidative stress indices including lipid hydroperoxide (LOOH), total antioxidant status (TAS), total oxidant status (TOS), oxidative stress index (OSI), paraoxonase (PON) and arylesterase (ARE) activities were measured in serum. CAD severity was assessed by calculating the SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery Study) score. We analyzed the association between the oxidative indices and CAD severity. RESULTS: Forty two young patients were admitted to the hospital with AMI (age 32.4 ± 2.6 years; 39 males, 3 females). Current and heavy smoking was commonly observed among the patients (79%). All patients underwent emergency coronary angiography. Twenty-eight healthy subjects were selected as controls. Patients had significantly higher OSI and TOS levels (median, interquartile range) [0.44 (0.26-1.75) vs 0.25 (0.22-0.30), p < 0.001 and 6.0 (4.4-20.8) vs 4.1 (3.7-4.6), p < 0.001], respectively, and lower TAS and LOOH levels [1.6 ± 0.1 vs 1.7 ± 0.1, p = 0.02 and 3.0 ± 0.8 vs 3.6 ± 0.4, p = 0.001], respectively, compared to the control group. CAD severity correlated positively with OSI (r = 0.508, p = 0.001) and TOS levels (r = 0.471, p = 0.002). Subjects with an intermediate to high SYNTAX score (≥ 22) demonstrated significantly higher OSI (median, interquartile range) [0.40 (0.34-1.75) vs 0.34 (0.26-0.68), p = 0.01] and TOS [6.9 (4.4-20.8) vs 5.8 (4.5-11.4), p = 0.01] levels compared to subjects with low SYNTAX score. CONCLUSIONS: Oxidative stress is an important contributor to CAD severity among young smokers. Elevated OSI and TOS levels reflect disease severity and vascular damage related to heavy smoking in early onset CAD.

Coronary calcium score, albuminuria and inflammatory markers in type 2 diabetic patients: associations and prognostic implications.

AIMS: To investigate the relationship of coronary artery calcium (CAC) scores with common carotid artery intima media thickness (CCA-IMT), albuminuria and inflammatory factors in type 2 diabetes. METHODS AND RESULTS: 128 asymptomatic type 2 diabetic patients, with at least one cardiovascular risk factor in addition to diabetes, were included in the study. CAC scores, carotid arteries plaque formation and CCA-IMT were assessed. The patients were followed for a mean period of 36.6 ± 3.3 months. Linear regression analysis identified the logarithmically transformed (Ln) albuminuria (ß=0.32, P=0.007), age (ß=0.04, P=0.001) and the uric acid (ß=0.13, P=0.04) as independent determinants of the CAC score. During follow-up period, cardiovascular events occurred in 18 out of 46 patients with CAC score ≥100 compared with 5 out of 82 patients with CAC score <100 (log rank, P<0.0001). Multivariate Cox proportional hazards analysis identified LnCAC score (P<0.0001), LnAlbuminuria (P=0.01) and uric acid (P=0.03) as independent predictors for cardiovascular events. CONCLUSIONS: There was a significant relationship between CAC score, albuminuria and inflammation in patients with type 2 diabetes. LnCAC score together with LnAlbuminuria and uric acid were identified as independent predictors of cardiovascular events in these patients.

Myocardial ischemia in severe aortic regurgitation despite angiographically normal coronary arteries.

Patients with severe aortic regurgitation frequently present with angina pectoris. The exact pathophysiology for angina in aortic regurgitation is not clear. Left ventricular hypertrophy and myocardial blood supply-demand mismatch have been the suggested mechanisms to explain ischemia. However, no conclusive clinical study exists to define the incidence of ischemia in patients with severe aortic regurgitation and normal coronary arteries. We, therefore, investigated the frequency of myocardial ischemia in relation to left ventricular hypertrophy or dilatation in patients with severe aortic regurgitation and normal coronary arteries. We reviewed the medical records of all patients (n = 311) with aortic valve replacement due to aortic regurgitation between 2007 and 2010. We selected subjects with normal coronary arteries (n =182) for the study purpose, and we identified 35 patients who underwent myocardial perfusion scintigraphy prior to the coronary angiography (19 female and 16 male subjects; age 45.0 ± 8.9 years). Left ventricular hypertrophy and dilatation were detected in 9 (26%) and 5 (14%) patients, respectively. Myocardial perfusion scintigraphy showed evidence of ischemia in 10 (29%) patients with normal coronary arteries. The presence of ischemia did not relate to the presence of left ventricular hypertrophy and/or dilatation. As a potential mechanism, aortic regurgitation causes backflow of blood from the aorta into the left ventricle, hence disturbs coronary flow dynamics. In conclusion, myocardial ischemia is common (nearly one-third) among patients with severe aortic regurgitation even in the absence of coronary obstruction, left ventricular hypertrophy and/or dilatation.

Effects of lecithin: cholesterol acyltransferase genotypes, enzyme levels, and activity on high-density lipoprotein levels.

BACKGROUND: Lecithin:cholesterol acyltransferase (LCAT) is one of the key enzymes controlling cholesterol homeostasis and plays a primary role in high-density lipoprotein cholesterol (HDL-C) maturation. OBJECTIVE: The aim of our study was to evaluate the effects of LCAT gene polymorphisms 511C/T (exon4), 4886C/T (rs5923), and 608C/T (rs5922) on LCAT enzyme level, activity, and HDL-C levels. METHODS: The study population was selected from consecutive subjects with low (<35 mg/dL) and high HDL-C levels (>65 mg/dL) seen in our lipid clinic. LCAT polymorphisms were analyzed with a restriction fragment length polymorphism assay. LCAT activity and levels were measured by colorimetric enzymatic and enzyme-linked immunoassay methods, respectively. RESULTS: The 4886C/T polymorphism was the most commonly observed variant of LCAT gene. T-allele frequencies in subjects with low (n = 50) and high (n = 50) HDL-C were 0.54 and 0.37, respectively (P = .019). TT genotype was more common among low HDL-C group (30% vs 14%, P = .05). The effects of LCAT enzyme appeared to depend on the HDL-C level. In subjects with low HDL-C, LCAT enzyme levels correlated positively with body mass index (P < .001, r = 0.544), HDL-C (P = .006, r = 0.404), triglycerides (P = .001, r = 0.487), total cholesterol (P < .001, r = 0.541), and low-density lipoprotein-cholesterol (P = .001, r = 0.477) levels. LCAT activity correlated positively with fasting glucose levels (P = .008, r = 0.390). CONCLUSION: LCAT genotype, enzyme level, and activity modulate HDL-C metabolism, particularly among subjects with low HDL-C levels.

The effects of blood pressure lowering on P-wave dispersion in patients with hypertensive crisis in emergency setting.

Hypertensive emergency refers to a severe hypertension (HT) that is associated with new or progressive end-organ damage. In these clinical situations, blood pressure (BP) should be reduced immediately to prevent or minimize organ dysfunction. The present study evaluated the diagnostic value of two electrocardiographic indices in detecting patients, who are at risk for paroxysmal atrial fibrillation (PAF), in the setting hypertensive crisis. The study population consisted of 30 consecutive patients aged ≥40 years, who were admitted to the emergency room with hypertensive crisis. Electrocardiographic (ECG) recordings of the patients were performed before and after the treatment. The minimum (Pmin) and maximum (Pmax) P wave duration on ECG, and P-wave dispersion (P(d)), which was defined as the difference between Pmin and Pmax, were measured. The mean P(d) was 118.0 ± 32.1 and 94.0 ± 44.3 before and after the treatment, respectively. The decrease observed in the mean P(d) was statistically significant (p = 0.005). The mean Pmax was 214.7 ± 37.1 before the treatment, while it was 194.0 ± 47.3 after the treatment, and the difference was significant (p = 0.021). The mean Pmin was 96.7 ± 26.3 and 100.0 ± 41.0 before and after the treatment, respectively; however, the difference was not significant (p = 0.624). Pmax and P(d) display significant changes with acute treatment of HT. There is a need for larger prospective studies to clearly elucidate the diagnostic value of ECG indices, Pmax and P(d) as indicators of future PAF.

Plasma soluble adhesion molecule levels in coronary artery ectasia.

BACKGROUND: Coronary artery ectasia (CAE) is defined as localized or diffuse dilatation of the coronary arteries. There are scarce data about the role of inflammation in CAE. In the present study, the plasma soluble adhesion molecules intercellular adhesion molecule 1 (ICAM-1) and vascular cell adhesion molecule 1 (VCAM-1) levels in CAE were investigated. METHODS: The study population (n = 67) consisted of four groups. Group 1: patients with normal coronary artery (NCA); group 2: patients with isolated ectasia without stenotic lesion; group 3: patients with obstructive coronary artery disease (OCAD) without CAE; group 4: patients with both OCAD and CAE. RESULTS: Plasma concentrations of ICAM-1 and VCAM-1 were higher in patients with isolated ectasia than in cases with NCA (p < 0.001 and p < 0.001, respectively). Compared with OCAD patients, patients with CAE had significantly elevated concentrations of ICAM-1 and VCAM-1 (p < 0.001 and p < 0.05, respectively). The levels of ICAM-1 and VCAM-1 of the CAE and OCAD group were higher than in patients in the OCAD group (p < 0.05 and p < 0.05, respectively). We detected a positive correlation between the presence of CAE and the levels of ICAM-1 and VCAM-1. Multivariate logistic regression analyses revealed a significant independent relation between the presence of CAE and ICAM-1 and VCAM-1. CONCLUSION: We found elevated plasma levels of ICAM-1 and VCAM-1 in patients with CAE and OCAD + CAE compared with subjects with NCA and OCAD. These data strongly suggest that more severe vascular wall inflammation may play a role in the pathogenesis of CAE.

Retinopathy is related to the angiographically detected severity and extent of coronary artery disease in patients with type 2 diabetes mellitus.

Diabetic retinopathy (DR) is an early and frequent marker of other vascular complications of diabetes and its relation with coronary ischemia is known. The aim of the present study was to evaluate the association between DR and indices of coronary artery disease (CAD) severity and extent determined by coronary angiography. Sixty-nine diabetic patients undergoing coronary angiography for suspected CAD were evaluated. The severity and extent of CAD were scored from coronary angiograms by using 3 scores. Retinopathy was graded by fundus examination. There were differences in the severity score, extent score, number of vessels with disease, duration of diabetes, diabetes therapy, history of previous myocardial infarction (MI), and serum creatinine level among patients with and without DR. CAD severity was associated with the presence of DR (r: 0.53, P < 0.001), grade of DR (r: 0.52, P < 0.001), duration of diabetes (r: 0.28, P: 0.019), history of previous MI (r: 0.36, P: 0.002); and serum creatinine level (r: 0.24, P: 0.049) where the presence of DR was the only independent factor related to the severity score in multivariate analysis (r: 0.48, P < 0.001). The parameters related to the extent score were the presence of DR (r: 0.50, P < 0.001); grade of DR (r: 0.48, P < 0.001); previous MI (r: 0.37, P: 0.002) and age of the patient (r: 0.26, P: 0.033). Factors independently related to the extent score in multivariate analysis were the presence of DR (r: 0.37, P: 0.001), previous MI (r: 0.30, P: 0.006), and age of the patient (r: 0.22, P: 0.003). Among diabetics who are suspected of having CAD, those with retinopathy have more diffuse and severe coronary atherosclerosis, compared with diabetics without retinopathy. This cannot be explained by a longer duration or inferior control of the disease.

[Assessment of the efficacy of bisoprolol administration by cardiopulmonary exercise testing in patients with heart failure]. / Kalp Yetersizliginde Bisoprolol Tedavi Etkinliginin Kardiyopulmoner Egzersiz Testi ile Degerlendirilmesi.

OBJECTIVE: It is well known that long-term therapy with beta-blockers reduces morbidity and mortality, improves left ventricular function in patients with heart failure. However the effect of beta-blockade on exercise tolerance in patients with heart failure remains unclear. In the present study we evaluated effects of the addition of bisoprolol to standart therapy with a diuretic and an angiotensin converting enzyme (ACE) inhibitor on exercise capacity in patients with chronic heart failure. METHODS: We enrolled 52 patients (mean age 59+/-11 years) with stable, mild to moderate chronic heart failure and left ventricular ejection fraction of 40% or less receiving standart therapy with diuretic and ACE inhibitor. We randomly assigned patients to bisoprolol 1.25 mg (n=28) or control (n=24) groups. The drug progressively increased to a maximum dose of 5 mg per day. Cardiopulmonary exercise testing (CPET) was performed in all patients of the bisoprolol and control groups before and after 3 months from the beginning of the study. RESULTS: We found a significant increase in exercise duration, maximal O2 uptake (pik VO2), the O2 uptake at the anaerobic threshold (VO2-AT) and O2-pulse (pik VO2/HR), and improved functional capacity (p<0.001). Bisoprolol produced significant reduction in heart rate at rest (p=0.01) and during maximal exercise (p=0.041). In the control group no significant changes were observed. CONCLUSION: The addition of bisoprolol to the standart therapy in patients with mild to moderate heart failure is well tolerated and improves functional capacity.

[Evaluation of success of mitral valvuloplasty in the early period with cardiopulmonary exercise test]. / Mitral valvüloplasti basarisinin erken dönem kardiyopulmoner egzersiz testi ile degerlendirilmesi.

OBJECTIVE: It was shown that percutaneous balloon mitral valvuloplasty (PMBV) has provided symptomatic improvement in cases with mitral stenosis. The purpose of this study was to investigate the influences of successful PBMV on cardiopulmonary exercise test (CPET) in patients with mitral stenosis early after intervention. METHODS: Twenty-nine patients with mitral stenosis were included in this study. Nineteen patients had undergone PBMV and ten patients were studied as control group. An incremental symptom limited CPET was carried out within the 24 hours before the PMVB procedure and within the five days thereafter. Breath by breath O2 uptake (VO2) and CO2 production (VCO2) were measured in these subjects. RESULTS: The mean mitral valve area (MVA) in the PBMV group before the procedure was 1.2 +/- 0.7 cm2 and the mean pressure gradient (PG) through the mitral valve was 12.63 +/- 4.87 mmHg; after the procedure, the mean MVA was 1.9 +/- 0.3 cm2 and the mean PG was 4.9 +/- 2.3 mmHg. The mean MVA in the control group was 1.4 +/- 0.16 cm2 and the mean PG was 7.2 +/- 3.54 mmHg. In the PBMV group, exercise time was 12.1 +/- 6 min before the procedure and increased to 18.75 +/- 5.5 min after the procedure (p = 0.0001); peak VO2 value rised from 1035 +/- 392 ml/min to 1178 +/- 373 ml/min (p = 0.0001) and VO2 at the anaerobic threshold from 667 +/- 286 ml/min to 772 +/- 268 ml/min (p = 0.006). Peak VO2/HR rised from 10.97 +/- 6.10 ml/min to 12.24 +/- 7.36 ml/min (p = 0.001). No significant difference was observed in the control group. CONCLUSIONS: The results of this study demonstrate that successful PBMV causes evident rise in exercise capacity, so that patients can manage the same exercise levels with lower heart rates and more economic ventilation.