Predictors of mortality in ST-elevation MI patients: A prospective study.

We aimed to define factors predicting mortality in patients having ST elevation myocardial infarction (STEMI) who had Primary Percutaneous Coronary Intervention (PCI) in our setting.This is a prospective study on patients presenting to the emergency department with STEMI who underwent PCI during a 12-month period. Physiological parameters were calculated using the vital signs and age of patients. Time-based factors in the institutional protocol were collected. Univariate analysis was performed to define significant factors that affected mortality. Significant factors were then entered into a logistic regression model. Factors significantly affecting mortality were defined. Receiving operating characteristic curve was applied to define the best predictors of mortality.A total of 167 consecutive patients were studied; 128 (76.6%) were males. The mean (SD) age of the patients was 61.9 (12.8) years. The logistic regression model showed that significant factors were age (P = .002), Modified Shock Index, MSI (P = .028), systolic blood pressure (P = .028), and time between consultation and activation of catheter laboratory (P = .047). The cut-off points with best prediction of mortality were age of 71.5 years, systolic blood pressure of less than 95 mmHg, MSI of 0.85, and a time more than 3.5 minutes between consultation and activation of catheter laboratory.Our study shows that significant predictors of 30-days mortality of STEMI were age, systolic blood pressure on presentation, MSI, and the time between consultation and catheter laboratory activation. Improving prehospital resuscitation and activation of the catheter laboratory by emergency physicians may reduce mortality in our setting.

Susceptiveness of Vitamin K epOxide Reductase Complex Subunit 1 Gene Polymorphism in Essential Hypertension.

BACKGROUND: Essential hypertension (EH) is defined as a worldwide public health problem and one of the important risk factors for development of human coronary artery disease. Increased peripheral arterial resistance is one of the distinguishing characteristics of EH. The extracellular deposition of calcium in the arterial wall is defined as vascular calcification, which results in aortic stiffness and elevation of blood pressure. Regulation of vascular calcification is physiologically limited by γ-carboxylated proteins that regulate mineralization. Any deficiencies related to mineralization influence vascular calcification. As a result of vitamin-K deficiency or any problem associated with the vitamin K epOxide reductase complex subunit 1 (VKORC1) gene, Glu cannot be transformed to Gla and calcification initiates in blood vessels, myocardium, and cardiac. OBJECTIVE: The aim of the study was to investigate the potential association of VKORC1 polymorphisms with the risk of EH. MATERIALS AND METHODS: There were 100 individuals diagnosed with EH and 100 healthy individuals involved in the study. 3673G/A (rs9923231) and 9041G/A (rs7294) polymorphisms in the VKORC1 gene were determined by the PCR-restriction fragment length polymorphism method. RESULTS: A significant difference was found between the rs7294 polymorphisms ratios of the case and control groups, but significant differences weren't found in distribution of the rs9923231 alleles. Finally it was determined that the GG genotype provides a 3.97-fold increased risk for EH compared to the AA genotype for the rs7294 polymorphism. CONCLUSIONS: Our results suggest that the VKORC1 gene rs7294 polymorphism is important for the development of EH.

The CYP2C19*2 and CYP2C19*17 Polymorphisms play a Vital Role in Clopidogrel Responsiveness after Percutaneous Coronary Intervention: A Pharmacogenomics Study.

Clopidogrel inhibits platelet activation and aggregation by blocking the P2Y12 receptor. Dual antiplatelet therapy with clopidogrel and aspirin is recommended treatment by current guidelines for patients undergoing percutaneous interventions. Recurrent ischaemic cardiac events after this treatment showed lack of clopidogrel responsiveness. We aimed to investigate the most noticeable variants in the genes involved in clopidogrel pharmacokinetics and pharmacodynamics. A total of 347 Turkish patients who underwent percutaneous coronary interventions with stent implantation were included in our study. Platelet reactivity (PRU) and % inhibition were measured with VerifyNow P2Y12 assay in blood samples collected from patients who took a standard dose of clopidogrel (75 mg/day) for at least 7 days. The variants in the CYP2C19, CYP3A4, CYP2B6, ABCB1, ITGB3 and PON1 genes were genotyped using the Sequenom MassARRAY system. When grouped, the patients with PRU values >208 as non-responsiveness to clopidogrel therapy; 104 (30%) patients were non-responders and 243 (70%) patients were responders. A significant association was found between the CYP2C19*2 (G636A) polymorphism and non-responsiveness to clopidogrel therapy (p < 0.001). An allele frequency of this single nucleotide polymorphism was high in non-responders; its odds ratio was 2.92 compared with G allele (p < 0.001). PRU values of CT genotypes were lower (p = 0.029) and % inhibition values of CT genotypes were higher (p = 0.008) compared with CC genotypes for the CYP2C19*17 (C806T) polymorphism. None of the other genetic variants were found to be statistically associated with non-responsiveness to clopidogrel and antiplatelet activity. Our findings suggest that the CYP2C19*2 polymorphism is associated with non-responsiveness to clopidogrel therapy and the CYP2C19*17 polymorphism enhances antiplatelet activity of clopidogrel. Depending on haplotypes of these two polymorphisms, clopidogrel-treated patients can be protected or not from stent thrombosis and ischaemic events.

[Turkish Hypertension Consensus Report]. / Türk Hipertansiyon Uzlasi Raporu.

Hypertension is a common and important public health problem in Turkey and worldwide. Recommendations on the diagnosis and treatment of hypertension have been presented in many nationally and internationally agreed European and American guidelines. However, there are differences among these guidelines, and some of the recommendations are not consistent with clinical practice in our country. Consensus report preparation, with the participation of relevant associations, was considered necessary to merge recommendations by evaluating hypertension guidelines from the perspective of Turkey and to create a joint approach in the diagnosis and treatment of hypertension in adults. For this purpose, it was aimed to prepare a practical text in Turkey in which all physicians dealing with hypertensive patients, from family practitioners in primary care to specialists in tertiary care, could come to agreement on common concepts, and which would be used as a basic reference guideline. Considering health care practices and sociocultural structure in Turkey, this report aimed to enhance awareness on hypertension, provide a common basis for different definitions and values as well as therapeutic options in various guidelines, and establish a practical reference guide to improve clinical practices in Turkey. This report is not a document describing hypertension in every aspect, but a reference, including basic recommendations with outlines. Care was taken to ensure that recommendations were evidence-based and valid for a majority of patients in clinical practice. However, it should be kept in mind that an approach assessment should be made on an individual basis for each patient.

Angiotensin II type 1 receptor (AT1) gene A1166C is associated with the risk of hypertension.

AIM: This study was performed on primary hypertension patients in a Turkish population to determine the frequency of the A1166C polymorphism in the angiotensin II type 1 receptor (AT1) gene and to examine the role of this polymorphism in hypertension development. MATERIALS AND METHODS: In this study, 250 genomic DNA samples were collected (from 142 hypertension patients and 108 healthy subjects), randomized, and analyzed. Genomic DNA was prepared from peripheral blood using the salt extraction method. The presence of the A1166C polymorphism in the AT1 gene was determined using the polymerase chain reaction (PCR)-restriction fragment length polymorphism method. PCR products were separated by 2% agarose gel electrophoresis and visualized by a charge-coupled device camera. RESULTS: Genotype distribution and allele frequency A1166C genotype frequency was determined as AA 96.3% and AC 3.7% for controls and as AA 86.6% and AC 13.4% for patients. A statistically significant difference was found between the control group and patients in terms of genotype and allele frequency. CONCLUSION: Our results suggest that an interaction exists between the AT1 gene polymorphism and hypertension in the Turkish population.

The use of low molecular weight heparin during pregnancy in patients with mechanical heart valves carries potential risk for valve thrombosis: a report of three cases.

Pregnancy is associated with an increased risk of valve thrombosis, hemorrhagic complications, and offspring complications in patients with metallic prosthetic heart valve (MHV). Warfarin treatment is the best regimen against thromboembolic complications, but its use in the first trimester can result in embryopathy. Low molecular weight heparin (LMWH) does not cross the placenta and has some potential advantages. However, the pharmacokinetics of LMWHs change during pregnancy, and serial monitoring of anti-Xa levels is strongly recommended. Despite this recommendation, LMWH therapy in a fixed dose is still used in pregnant women with MHV without monitoring anti-Xa activity in clinical practice. We present three cases of MHV thrombosis occurring while on therapy with LMWH during pregnancy. One of these patients showed cerebrovascular event, one presented with pulmonary edema, and one underwent reoperation for MHV thrombosis.

Effects of metoprolol and nebivolol on exercise blood pressure in patients with mild hypertension.

OBJECTIVES: We planned to compare the impact of two beta blockers, metoprolol and nebivolol, on arterial blood pressure during exercise in patients with mild hypertension. METHODS: A total of 60 patients (13 males, 47 females; mean age: 54.3 ± 10.7 years) were enrolled in the present study. The patients were randomly selected to receive either nebivolol 5 mg/day (n = 30) or metoprolol 50 mg/day (n = 30) for 8 weeks. At the end of the 8th week, each of the patients received exercise stress test according to Bruce protocol and their blood pressures were remeasured after rest, exercise, and recovery. RESULTS: Blood pressures were determined to be similar between metoprolol and nebivolol groups during rest, exercise, and recovery periods. Metoprolol and nebivolol achieved similar reductions in blood pressures during rest and exercise. However, five patients in nebivolol group and four patients in metoprolol group developed exaggerated BP response to exercise but the difference between metoprolol and nebivolol was not meaningful (P = 0.37). CONCLUSION: The results of the present study showed that metoprolol and nebivolol established comparable effects on the control of blood pressures during exercise in the patients with mild hypertensions.

Diagnostic value of heart-type fatty acid binding protein determined by the rapid qualitative chromatographic immunoassay method for the detection of minor myocardial damage in patients presenting with non-ST elevation acute coronary syndrome.

OBJECTIVE: The aim of this prospective study was to evaluate the diagnostic value of heart-type fatty acid binding protein (H-FABP) determined by qualitative immunoassay method for the detection of minor myocardial damage (MMD) in patients with non-ST elevation acute coronary syndrome (NSTE-ACS). METHODS: The study consisted of 62 patients with NSTE-ACS. Cardiac troponin I (cTnI) and creatine kinase MB isoenzyme (CK-MB) values were measured at arrival. Myoglobin and H-FABP were obtained if cTnI level was found to be elevated. A control group included 20 subjects with normal cTnI and CK-MB values. H-FABP was determined by a rapid qualitative immunochromatographic test. Patients were classified as MMD-ACS group if they had abnormal cTnI and normal CK-MB (n=24) and as NSTEMI-ACS group if they had elevated both cTnI and CK-MB (n=38). The diagnostic accuracy of H-FABP for minor myocardial damage was determined using ROC analysis. RESULTS: The sensitivity of the H-FABP was significantly higher for NSTEMI-ACS than for MMD-ACS (44.7% vs 0%, p<0.001) and its specificity was 95% for both groups. The diagnostic efficacy rates for myoglobin and H-FABP were 75% and 43% for MMD-ACS, 74% and 62% for NSTEMI-ACS. Positive predictive value for H-FABP and myoglobin were found to be 0% and 80.8% in MMD-ACS, 94% and 87% in NSTEMI-ACS and negative predictive value was 44% and 69.5% in MMD-ACS, 47.5% and 59% in NSTEMI-ACS, respectively. AUC for myoglobin was significantly greater than that for H-FABP in MMD-ACS group (0.754 vs 0.525, p=0.027). The sensitivity of the H-FABP was significantly higher in patients with >3-fold increase in cTnI than those with <3-fold increase in cTnI (46.8% vs. 6.7%, p<0.001). A positive correlation was found between the magnitude of cTnI rise and H-FABP results (r=0.45, p<0.001). CONCLUSIONS: H-FABP determined by the rapid qualitative immunochromatographic test has almost similar diagnostic value to that of myoglobin for identifying NSTEMI-ACS, however, does not seem to represent diagnostic potential for the detection of MMD.

Asymptomatic course of a metastatic mass completely filling the right atrium in a patient with hepatocellular carcinoma.

Intracardiac involvement rarely develops in patients with hepatocellular carcinoma (HCC) and its prognosis is poor. Patients generally have symptoms of sudden dyspnea or massive lower extremity edema and the clinical course may be further complicated by many fatal cardiovascular complications. Absence of cardiac symptoms or findings, however, is an unusual condition. We present a 61-year-old man with HCC who was incidentally found to have an intracavitary mass completely occupying the right atrium. He had no cardiac complaints, nor any signs of cardiac involvement. The mass was first detected by computed tomography and then confirmed by transthoracic echocardiography. The patient underwent a successful surgical resection and the histopathologic diagnosis was HCC. Unfortunately, the postoperative course was complicated by the development of acute kidney failure and, despite hemodialysis treatment, the patient died of kidney failure eight days after the operation.

An observational study to evaluate factors responsible and actions taken for hypertensive patients who are not at blood pressure goal: i-target Goal Study.

To evaluate the percentage of hypertensive patients who could achieve target blood pressure (TBP) according to the guidelines in the context of recommended measures and the factors responsible for failure. A total of 589 hypertensive patients (59.0% female; mean age: 57.7 ± 10.4 years) were assessed twice for TBP achievement based on 2007 ESH/ESC guidelines and the investigators' view, in addition to the recommended measures and possible causes of failure in hypertension management in this national multi-center (n = 99), non-interventional observational study. Only 29.5% of the patients at the first visit and 46.8% at the second visit achieved the TBP levels specified by the guidelines. However, the investigators' evaluation indicated a higher achievement rate at the first (43.5%) as well as the second (69.1%) visit when compared with the guideline-based assessments (P < 0.001). The primary reasons identified by the investigators for the failure to reach TBP were non-compliance with dietary recommendations (61.6%) at the first visit and non-compliance with treatment (63.92%) at the second visit. Recommendations for lifestyle were the most commonly identified treatment plan by the investigators at both visits (62.9% and 66.1%, respectively). Although more patients achieved the TBP levels specified by the guidelines for the second visit compared with the first, effective blood pressure control was achieved only in 29.5% of our patients. Interestingly, the investigators had a more optimistic view about their patients' control of hypertension, which may have contributed to a poor achievement of TBP.

Effectiveness of cardiac simulator on the acquirement of cardiac auscultatory skills of medical students.

BACKGROUND: Cardiac simulators have been developed as an alternative training model in order to improve the cardiac auscultation skills of medical students. The effectiveness of the cardiac simulator's use in cardiac auscultatory training is presently not yet well established. OBJECTIVES: The authors aimed to investigate whether the use of a cardiac simulator can improve the auscultation skills of medical students. MATERIAL AND METHODS: The students taking the auscultation training on the cardiac simulator were grouped as Group A and the students not taking the auscultation training on the cardiac simulator were grouped as Group B (before). The students in Group B (before) were grouped as Group B (after) after receiving the auscultation training on the cardiac simulator. The percentages of accurate diagnoses for the tested heart murmurs were compared between Group A and Group B (before), and between Group B (before) and Group B (after). RESULTS: The rate of making correct diagnoses of normal heart sounds was similar in all the groups (Group A, Group B (before), and Group B (after)). By contrast, the percentage of accurate diagnoses for the tested heart murmurs was notably improved among the students in Group A with respect to Group B (before) (p < 0.01). Similarly, the rate of correct diagnoses for the tested heart murmurs was markedly higher among the students in Group B (after) than in Group B (before) (p < 0.01). CONCLUSIONS: The use of a cardiac simulator as a training tool can improve the auscultation skills of medical students quickly and efficiently.

Gender differences in the types and frequency of coronary artery anomalies.

Coronary artery anomalies are rarely encountered in general population. Gender may play a role in the types and incidence of coronary artery anomalies, although the effect of gender is not well established. In the present study, we therefore aimed to investigate the frequency and location of various types of coronary artery anomalies and their correlation with gender. We assessed retrospectively the coronary angiography movies of 7,810 patients (2,214 females and 5,596 males), the method of which is distinct from the earlier studies with angiographic archive records. We defined and classified the coronary artery anomalies according to their origin, course (myocardial bridge), and termination (fistula). The incidence of coronary artery anomalies was 3.35% (262 of 7,810): 130 individuals with anomalous origin (1.66%), 105 individuals with myocardial bridges (1.34%), and 27 with fistulas (0.35%). The frequency of the coronary artery anomalies was significantly higher in the females than the males (p = 0.001). Of the coronary artery origin anomalies, the circumflex and the left anterior descending artery originating from separate ostia in the left aortic sinus were higher in the females compared to the males (P < 0.001). In contrast, the frequency of myocardial bridges was higher in the males (P = 0.01). No gender difference was detected in fistulas. Thus, gender affects the types of coronary artery anomalies, except for fistulas. The determination of the presence of the coronary artery anomalies during the coronary angiography is critical for the planning of the treatment and for the proper clinical follow-up of patients.

[Our initial experience with stent implantation for aortic coarctation in adults]. / Eriskinlerde aort daralmasinin stent ile tedavisine iliskin ilk deneyimlerimiz.

OBJECTIVES: We evaluated the procedural success and short-mid term results of stent implantation for aortic coarctation in adults. STUDY DESIGN: The study included 15 consecutive patients (9 women, 6 men; mean age 27±7 years; range 17 to 45 years) treated with stent implantation for aortic coarctation. Fourteen patients had native, one patient had recurrent coarctation. Nine patients received bare metal and six patients received covered Cheatham-Platinum stents. Covered stents were used in patients with accompanying patent ductus arteriosus (n=2), severe coarctation (n=3), and recurrent coarctation (n=1). Procedural success was defined as the reduction in the pressure gradient across the coarctation site to less than 20 mmHg. The mean follow-up period was 10.4±4.6 months (range 3 to 18 months). RESULTS: Stent implantation was successful in all the patients. Compared to the preprocedure figures, systolic gradient across the aortic coarctation decreased from 37.2±11.3 mmHg to 3.5±2.9 mmHg, the diameter of the coarcted aortic segment increased from 5.4±1.5 mm to 17.2±1.4 mm, and systolic blood pressure declined from 154±9.7 mmHg to 130±7.3 mmHg following stenting (for all, p<0.001). There were no procedure-related major complications. CONCLUSION: Stent implantation for aortic coarctation in adults is a safe and effective alternative to surgical correction.

Mode of onset of polymorphic ventricular tachycardia in acute myocardial infarction.

BACKGROUND: Polymorphic ventricular tachycardia (PVT) can occur during acute myocardial infarction (MI). In the past, studies investigated the initiation pattern of ventricular tachycardias in different patient populations; however, the mode of onset of PVT in acute MI patients has not been investigated previously. OBJECTIVE: To retrospectively investigate the electrophysiological features of PVT with different initiation patterns in acute MI patients to assess whether there is a relationship of the initiation patterns of PVT with clinical and electrophysiological characteristics. METHODS: Sixty-two rhythm strips defined as PVT from 53 patients (mean [± SD] age 63±8 years) with acute ST elevation MI were analyzed. All patients were monitored while they were hospitalized in the coronary care unit, and the electrocardiogram strips were obtained from continuous monitoring. PVT was defined as sudden-onset tachycardia if it was not preceded by ventricular ectopic beats. PVT that was preceded by single or multiple ectopic beats was defined as nonsudden-onset tachycardia. RESULTS: Nonsudden-onset episodes were more common than suddenonset episodes (40 episodes [64.5%] versus 22 episodes [35.5%]). In the nonsudden-onset group, 25 episodes (62.5%) were initiated after a single ectopic beat, while 15 episodes (37.5%) were initiated after multiple complexes. The mean (± SD) left ventricular ejection fraction of patients with nonsudden-onset PVT was decreased (53±6% versus 65±7%, P<0.01). Nonsudden-onset tachycardias had lower coupling intervals than suddenonset tachycardias. Similarly, the PVT cycle length was shorter in the presence of nonsudden-onset initiation. When nonsudden-onset PVT episodes were further subclassified based on the morphology of the first beat of tachycardia, 26 PVTs (65%) had a first beat of tachycardia similar to the subsequent PVT beats and 14 (35%) did not. CONCLUSIONS: These results demonstrate that PVT is often preceded by ventricular ectopy in acute MI patients. Nonsudden-onset PVT is usually characterized by a lower coupling interval, shorter PVT cycle length and an associated lower ejection fraction.

Plasminogen activator inhibitor type-1 gene 4G/5G polymorphism is associated with hypertensive patients in the Turkish population.

This study has been performed on hypertensive patients in the Turkish population to determine the frequency of 4G/5G polymorphism genotypes of plasminogen activator inhibitor type-1 gene and with the aim of examining the role of this polymorphism in hypertension development. Genomic DNA obtained from 284 persons (176 patients with hypertension and 108 healthy controls) was used in the study. DNA was multiplied by polymerase chain reaction using 4G and 5G allele-specific primers. Polymerase chain reaction products were assessed by being exposed to 2% agarose gel electrophoresis. Results were evaluated with the chi-square test. The 4G allele frequency was 31.25% and the 5G allele frequency was 68.75% in patients, whereas it was 49/51% in a control group. 5G5G genotype was found statistically high (p < 0.001) in patients relative to controls. This study showed that the plasminogen activator inhibitor type-1 gene 4G/5G polymorphism and the 5G5G genotype appear to be associated with an elevated risk of developing hypertension in a representative sample of Turkish population.

[Levosimendan and dobutamine have a similar profile for potential risk for cardiac arrhythmias during 24-hour infusion in patients with acute decompensated heart failure]. / Levosimendan ve dobutamin akut dekompanse kalp yetersizliginde 24 saatlik infüzyon sirasinda benzer aritmi potansiyeli göstermektedir.

OBJECTIVES: Unlike traditional inotropic agents, levosimendan is thought to have a lower potential to induce arrhythmias because it does not increase intracellular calcium levels and myocardial oxygen consumption. We compared the potential effect of levosimendan and dobutamine to induce cardiac arrhythmias in patients with decompensated heart failure. STUDY DESIGN: Fifty patients with acute decompensated heart failure (NYHA class III-IV, ejection fraction <35%) who were in need of inotropic support were randomized to dobutamine (n=25; mean age 69±10 years) or levosimendan (n=25; mean age 67.5±11.5 years) and underwent 24-hour Holter monitoring before and during inotropic infusion. Holter recordings were analyzed with respect to heart rate (HR), ventricular premature contraction (VPC), couplets of VPC, supraventricular premature contraction (SVPC), paroxysmal atrial fibrillation (PAF), and nonsustained ventricular tachycardia (NSVT). RESULTS: Before infusions, the two groups were similar with respect to HR, VPC, couplets of VPC, SVPC, and PAF episodes, but the number of NSVT episodes was significantly higher in the levosimendan group. Heart rate and the number of VPCs increased significantly during infusions of levosimendan (p=0.036 and p<0.001, respectively) and dobutamine (for both p<0.001). Increase in couplets of VPC was significant only with dobutamine (p=0.012). The episodes of NSVT and PAF increased with levosimendan, without reaching significance. Levosimendan and dobutamine groups were similar in terms of percentage changes in arrhythmias (55±224% vs. 11±16% for VPC; 2±2.7% vs. 12±9% for couplets of VPC; 3.4±5.8% vs. 16±39% for SVPC, 0.4±2.8% vs. -2±0% for NSVT) and percentage change in total arrhythmias (41±190% vs. 18±35.4%), and the mean HR, VPC, couplets of VPC, SVPC, and episodes of NSVT and PAF (p>0.05). CONCLUSION: Our findings suggest that levosimendan and dobutamine have a similar profile for potential risk for cardiac arrhythmias.