Six-Minute Walk Test: How to do Guide for Performing a Reliable Test, Interpretation, and Prognostication in Pulmonary Hypertension.

Six-minute walk test (6MWT) is the most widely used exercise capacity measurement worldwide in patients with pulmonary hypertension (PH). Although cardiopulmonary exercise testing (CPET) is the gold standard for the assessment of exercise capacity in cardiovascular diseases; the limited accessibility of the device, the need for experience in interpreting the results, and the difficulties in performing CPET in advanced PH have aroused the interest in the application of easier methods for the measurement of exercise capacity. Since then, accumulated data proved that; 6-minutes walking distance (6MWD) can be used to determine exercise capacity and is highly correlated with maximum oxygen consumption (peak VO2) detected by CPET in patients with heart failure and/or PH. Moreover, 6MWT is very easy and practical to apply in all PH subgroups. This review is focused on the application of a reliable 6MWT and the interpretation of the results in patients with PH.

Anti-inflammatory treatment improves systolic and diastolic tissue doppler parameters in patients with newly diagnosed rheumatoid arthritis.

BACKGROUND: The frequency of cardiovascular system involvement is increased in rheumatoid arthritis (RA) and may result in serious morbidity and mortality. Early intervention and control of the disease activity may reduce the risk of cardiovascular events. The purpose of this study is to examine the effects of steroids and methotrexate (Mtx) on the heart functions of newly diagnosed RA patients. METHODS: Our study is a prospective cohort study involving thirty-six newly diagnosed RA patients according to the American Society of Rheumatology classification criteria. Right and left ventricular echocardiography, and Doppler parameters were evaluated in these patients thrice; before treatment, after one month of steroid treatment, and after three months of Mtx treatment, and laboratory/clinical parameters were noted. RESULTS: The mean age of the patients was 52.66 ± 13.66 years. After the treatment, a significant decrease was observed in the values of inflammatory markers (ESR and CRP) and disease activity score (DAS28) [p < .05]. Left ventricular tissue Doppler showed an increase in lateral S, septal S, and mitral S waves compared to baseline (8.37 ± 1.89 vs 10.0 ± 1.8 cm/s p = .001). While there was a decrease in tissue Doppler tricuspid a wave (18.33 ± 4.76 vs 15.63 ± 4.36 p = .016), an increase in Tricuspid E/e' value and Tricuspid tissue Doppler e/a value was detected after treatment (0.76 ± 0.30) vs 0.94 ± 0.53) p < .010). Significant changes were found to be more prominent after the Mtx treatment. CONCLUSION: In RA patients, steroid and Mtx treatment significantly positively affects left ventricular systolic and right ventricular diastolic functions.

Frailty Significantly Associated with a Risk for Mid-term Outcomes in Elderly Chronic Coronary Syndrome Patients: a Prospective Study.

INTRODUCTION: Frailty is a condition of elderly characterized by increased vulnerability to stressful events. Frail patients are more likely to have adverse events. The purposes of this study were to define frailty in patients aged ≥ 70 years with chronic coronary syndrome (CCS) and to evaluate mortality and prognostic significance of frailty in these patients. METHODS: We included 99 patients, ≥ 70 years old (mean age 74±5.3 years), with diagnosis of CCS. They were followed-up for up to 12 months. The frailty score was evaluated according to the Canadian Study of Health and Aging (CSHA). All patients were divided as frail or non-frail. The groups were compared for their characteristics and clinical outcomes. RESULTS: Fifty patients were classified as frail, and 49 patients as non-frail. The 12-month Major Adverse Cardiac Events (MACE) rate was 69.4% in frail patients and 20% in non-frail patients. Frailty increases the risk for MACE as much as 3.48 times. Two patients died in the non-frail group and 11 patients died in the frail group. Frailty increases the risk for death as much as 6.05 times. When we compared the aforementioned risk factors by multivariate analysis, higher CSHA frailty score was associated with increased MACE and death (relative risk [RR] = 22.94, 95% confidence interval [CI] 3.33-158.19, P=0.001, for MACE; RR = 7.41, 95% CI 1.44-38.03, P=0.016, for death). CONCLUSION: Being a frail elderly CCS patient is associated with worse outcomes. Therefore, frailty score should be evaluated for elderly CCS patients as a prognostic marker.

Predictive value of plasma copeptin level for diagnosis and mortality of pulmonary embolism.

OBJECTIVE: Early diagnosis and risk stratification may provide a better prognosis in pulmonary embolism (PE). Copeptin has emerged as a valuable predictive biomarker in various cardiovascular diseases. The aim of this study was to determine the levels of copeptin in patients with acute PE and to evaluate its relationship with disease severity and PE-related death. METHODS: Fifty-four patients and 60 healthy individuals were included in this study. Copeptin concentrations and right ventricular dysfunction were analyzed. The correlation between copeptin levels and hemodynamic and echocardiographic parameters was examined. After these first measurements, patients were evaluated with PE-related mortality at the one-year follow-up. RESULTS: The copeptin levels were higher in PE patients than in the control group (8.3 ng/mL vs 3.8 ng/mL, p<0.001). Copeptin levels were found to be significantly higher in patients with PE-related death and right ventricular dysfunction (10.2 vs 7.5 ng/ml, p=0.001; 10.5 vs 7.5 ng/ml, p=0.002, respectively). When the cut-off value of copeptin was ≥5.85, its sensitivity and specificity for predicting PE were 71.9% and 85.0%, respectively (AUC=0.762, 95% CI=0.635-0.889, p<0.001). CONCLUSIONS: The copeptin measurement had moderate sensitivity and specificity in predicting the diagnosis of PE, and the copeptin level was significantly higher in patients with PE-related death at the one-year follow-up. Copeptin may be a useful new biomarker in predicting diagnosis, risk stratification, and prognosis of PE.

Predictive value of plasma copeptin level for diagnosis and mortality of pulmonary embolism

SUMMARY OBJECTIVE: Early diagnosis and risk stratification may provide a better prognosis in pulmonary embolism (PE). Copeptin has emerged as a valuable predictive biomarker in various cardiovascular diseases. The aim of this study was to determine the levels of copeptin in patients with acute PE and to evaluate its relationship with disease severity and PE-related death. METHODS: Fifty-four patients and 60 healthy individuals were included in this study. Copeptin concentrations and right ventricular dysfunction were analyzed. The correlation between copeptin levels and hemodynamic and echocardiographic parameters was examined. After these first measurements, patients were evaluated with PE-related mortality at the one-year follow-up. RESULTS: The copeptin levels were higher in PE patients than in the control group (8.3 ng/mL vs 3.8 ng/mL, p<0.001). Copeptin levels were found to be significantly higher in patients with PE-related death and right ventricular dysfunction (10.2 vs 7.5 ng/ml, p=0.001; 10.5 vs 7.5 ng/ml, p=0.002, respectively). When the cut-off value of copeptin was ≥5.85, its sensitivity and specificity for predicting PE were 71.9% and 85.0%, respectively (AUC=0.762, 95% CI=0.635-0.889, p<0.001). CONCLUSIONS: The copeptin measurement had moderate sensitivity and specificity in predicting the diagnosis of PE, and the copeptin level was significantly higher in patients with PE-related death at the one-year follow-up. Copeptin may be a useful new biomarker in predicting diagnosis, risk stratification, and prognosis of PE.

RESUMO OBJETIVO: O diagnóstico precoce e a estratificação de risco podem proporcionar um melhor prognóstico em casos de embolia pulmonar (EP). A copeptina surgiu como um valioso biomarcador preditivo de várias doenças cardiovasculares. O objetivo deste estudo é determinar os níveis de copeptina em pacientes com EP aguda e avaliar a sua relação com a severidade da doença e mortes relacionadas à EP. MÉTODOS: Um total de 54 pacientes e 60 indivíduos saudáveis foram incluídos neste estudo. As concentrações de copeptina e disfunções ventriculares direitas foram analisadas. A correlação entre os níveis de copeptina e parâmetros ecocardiográficos e hemodinâmicos foi examinada. Após essas primeiras medições, os pacientes foram avaliados em relação à mortalidade relacionada à EP após um ano. RESULTADOS: Os níveis de copeptina foram maiores em pacientes com EP do que no grupo de controle (8,3 ng/mL vs 3,8 ng/mL, p<0,001). Os níveis de copeptina eram significativamente maiores em pacientes com mortes relacionadas à EP e disfunção ventricular direita (10,2 vs 7,5 ng/ml, p=0,001; 10,5 vs 7,5 ng/ml, p=0,002, respectivamente). Com um valor de corte ≥5,85 para a copeptina, sua sensibilidade e especificidade preditivas para EP foram 71,9% e 85,0%, respectivamente (AUC=0,762, 95% IC=0,635 - 0,889, p<0,001). CONCLUSÃO: A medição da copeptina teve sensibilidade e especificidade preditivas moderadas para o diagnóstico de EP, e o nível de copeptina foi significativamente maior em pacientes com mortes relacionadas à EP após um ano. A copeptina pode ser um novo biomarcador preditivo útil para o diagnóstico, a estratificação de risco e o prognóstico de PE.

Frailty significantly associated with a risk for mid-term outcomes in elderly chronic coronary syndrome patients: a prospective study

Abstract Introduction: Frailty is a condition of elderly characterized by increased vulnerability to stressful events. Frail patients are more likely to have adverse events. The purposes of this study were to define frailty in patients aged ≥ 70 years with chronic coronary syndrome (CCS) and to evaluate mortality and prognostic significance of frailty in these patients. Methods: We included 99 patients, ≥ 70 years old (mean age 74±5.3 years), with diagnosis of CCS. They were followed-up for up to 12 months. The frailty score was evaluated according to the Canadian Study of Health and Aging (CSHA). All patients were divided as frail or non-frail. The groups were compared for their characteristics and clinical outcomes. Results: Fifty patients were classified as frail, and 49 patients as non-frail. The 12-month Major Adverse Cardiac Events (MACE) rate was 69.4% in frail patients and 20% in non-frail patients. Frailty increases the risk for MACE as much as 3.48 times. Two patients died in the non-frail group and 11 patients died in the frail group. Frailty increases the risk for death as much as 6.05 times. When we compared the aforementioned risk factors by multivariate analysis, higher CSHA frailty score was associated with increased MACE and death (relative risk [RR] = 22.94, 95% confidence interval [CI] 3.33-158.19, P=0.001, for MACE; RR = 7.41, 95% CI 1.44-38.03, P=0.016, for death). Conclusion: Being a frail elderly CCS patient is associated with worse outcomes. Therefore, frailty score should be evaluated for elderly CCS patients as a prognostic marker.

Acute Anterior Myocardial Infarction in a Patient With Dextrocardia and Situs Inversus: An Unusual Coexistence.

Situs inversus totalis is a rare disorder. In addition, acute coronary syndromes, especially ST-segment elevation myocardial infarctions, are rarely detected in this group. We demonstrate the electrocardiographic features and discuss the interventional challenges of acute anterior myocardial infarction in a patient with dextrocardia. (Level of Difficulty: Beginner.).

Predictors of the paroxysmal atrial fibrillation recurrence following cryoballoon-based pulmonary vein isolation: Assessment of left atrial volume, left atrial volume index, galectin-3 level and neutrophil-to-lymphocyte ratio.

BACKGROUND: Cryoballoon-based pulmonary vein isolation (PVI) is a treatment option for atrial fibrillation (AF). Left atrial volume (LAV) and left atrial volume index (LAVi) are important parameters for long term success of PVI. Galectin-3 (Gal-3) and neutrophil to lymphocyte ratio (N/L ratio) are biomarkers to demonstrate the cardiac fibrosis and remodelling. METHODS: 50 patients with symptomatic PAF despite ≥1 antiarrhythmic drug(s), who underwent PVI were enrolled. LAV, LAVi, Gal-3 and N/L ratio were calculated before ablation and after ablation at 6 and 12 months. According to AF recurrence patients were divided into two groups, recurrent AF (n = 14) and non-recurrent AF (n = 36). RESULTS: In both groups (recurrent and non-recurrent), initial and 12 months follow-up LAV values were 41.39 ±â€¯18.13 ml and 53.24 ±â€¯22.11 ml vs 48.85 ±â€¯12.89 ml and 42.08 ±â€¯13.85 (p = 0.037). LAVi were 20.9 ±â€¯8.91 ml/m2 and 26.85 ±â€¯11.28 ml/m2 vs 25.36 ±â€¯6.21 and 21.87 ±â€¯6.66 (p = 0.05) for recurrent and non-recurrent AF groups, respectively. In both groups PVI had no significant effect on serum Gal-3 levels and N/L ratio during 12 months follow-up. The comparison between two groups at the end of 12th month showed Gal-3 values of 6.66 ±â€¯4.09 ng/ml and 6.02 ±â€¯2.95 ng/ml (p = 0.516), N/L ratio values of 2.28 ±â€¯1.07 103/µl and 1.98 ±â€¯0.66 103/µl (p = 0.674). CONCLUSION: LAV and LAVi are useful to predict the remodelling of the left atrium and AF recurrence after cryoballoon-based PVI. However, biomarkers such as Gal-3 and N/L ratio are not associated with AF recurrence.

Is atrial fibrillation a risk factor for contrast-induced nephropathy in patients with ST-elevation myocardial infarction?

BACKGROUND: Contrast-induced nephropathy (CIN) is an iatrogenic problem in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). Atrial fibrillation (AF) may also contribute to impaired kidney function. Several factors may contribute to the development of CIN. In patients with STEMI, concomitant AF is associated with higher in-hospital/follow-up mortality and morbidity. Therefore, we aimed to investigate the relationship between AF and CIN developments. METHODS: In this study, 650 consecutive STEMI patients treated with PPCI were enrolled. Patients with AF at admission who did not achieve a sinus rhythm during 48h after hospitalization were defined as AF patients. CIN was defined by an increase in serum creatinine by >25% or 0.5mg/dL within 72h following contrast media exposure. RESULTS: Our patients were divided into two groups based on whether they had AF, and although warfarin usage was different, the other parameters were similar between the groups. When our patients were grouped according to CIN development [group 1: CIN (+), group 2: CIN (-)], creatinine levels prior to PPCI (p=0.020), estimated glomerular filtration rate (eGFR) prior to PPCI (p<0.001), left ventricular ejection fraction (LVEF) (p=0.011), AF (p<0.001), and warfarin usage (p=0.016) were different between the two groups. We also performed multivariate logistic regression analyses and found that AF [odds ratio (OR), 6.945; 95% confidence interval (CI), 2.789-17.293; p<0.001], eGFR (OR, 0.973; 95% CI, 0.957-0.989; p=0.001), and LVEF (OR, 0.963; 95% CI, 0.935-0.991; p=0.010) independently predicted CIN development in patients with STEMI. CONCLUSIONS: The risk factors for CIN are multifactorial and identifying high-risk patients is the most important step for prevention. In addition to traditional risk factors, AF can contribute to CIN development in patients with STEMI.

The Incidence and the Risk Factors of Silent Embolic Cerebral Infarction After Coronary Angiography and Percutaneous Coronary Interventions.

Silent embolic cerebral infarction (SECI) is a major complication of coronary angiography (CAG) and percutaneous coronary intervention (PCI). Patients with stable coronary artery disease (CAD) who underwent CAG with or without PCI were recruited. Cerebral diffusion-weighted magnetic resonance imaging was performed for SECI within 24 hours. Clinical and angiographic characteristics were compared between patients with and without SECI. Silent embolic cerebral infarction occurred in 12 (12%) of the 101 patients. Age, total cholesterol, SYNTAX score (SS), and coronary artery bypass history were greater in the SECI(+) group (65 ± 10 vs 58 ± 11 years,P= .037; 223 ± 85 vs 173 ± 80 mg/dL,P= .048; 30.1 ± 2 vs 15 ± 3,P< .001; 4 [33.3%] vs 3 [3.3%],P= .005). The SECI was more common in the PCI group (8/24 vs 4/77,P= .01). On subanalysis, the SS was significantly higher in the SECI(+) patients in both the CAG and the PCI groups (29.3 ± 1.9 vs 15 ± 3,P< .01; 30.5 ± 1.9 vs 15.1 ± 3.2,P< .001, respectively). The risk of SECI after CAG and PCI increases with the complexity of CAD (represented by the SS). The SS is a predictor of the risk of SECI, a complication that should be considered more often after CAG.

Ultrasound Accelerated Thrombolysis May Be an Effective and Safe Treatment Modality for Intermediate Risk/Submassive Pulmonary Embolism.

Pulmonary embolism (PE) is a potentially life-threatening condition and the fact that 90% of PE originate from lower limb veins highlights the significance of early detection and treatment of deep vein thrombosis. Massive/high risk PE involving circulatory collapse or systemic arterial hypotension is associated with an early mortality rate of approximately 50%, in part from right ventricular (RV) failure. Intermediate risk/submassive PE, on the other hand, is defined as PE-related RV dysfunction, troponin and/or B-type natriuretic peptide elevation despite normal arterial pressure. Without prompt treatment, patients with intermediate risk PE may progress to the massive category with a potentially fatal outcome. In patients with PE and right ventricular dysfunction (RVD), in hospital mortality ranges from 5% to 17%, significantly higher than in patients without RVD.

Electrocardiographic markers of left ventricular systolic dysfunction in patients with left bundle branch block.

BACKGROUND: Although some patients with left bundle branch block (LBBB) have structural heart diseases, some patients with LBBB have "normal hearts". The electrocardiography (ECG) criteria of LBBB in reduced left ventricular ejection fraction (LVEF) have not been defined completely. AIM: The main purpose of this study was to differentiate patients with reduced LVEF from patients with normal left ventricular systolic function simply by analysing 12-lead ECG. METHODS: Subjects admitted to our hospital with LBBB in their ECG were included in the study. The patients were categorised according to their left ventricular systolic function as group 1 (LVEF ≥ 50%) and group 2 (LVEF < 50%). Duration of the QRS complex, residual conduction of left bundle branch, and concordance/discordance of T waves in leads V5, V6, or D1 were recorded. The ECG findings of the two groups were compared. RESULTS: One hundred consecutive patients with LBBB were included in the study (male/female: 56/44, age: 66 ± 15 years). In the whole group, there were 35 patients with normal left ventricular systolic function (LVEF ≥ 50%), and 65 patients had LVEF below 50%. 80% of male patients with LBBB and 45% of female patients with LBBB had their LVEF below 50% (p < 0.001). Mean QRS durations of group 1 and group 2 were 132 ± 10 ms vs. 152 ± 22 ms, respectively (p < 0.001). The QRS duration of 140 ms was found to be the cut-off value to differentiate group 1 from group 2, with sensitivity and specificity of 72% and 75%, respectively. Twenty-one per cent of patients in group 1 and 69% in group 2 had discordant LBBB (p < 0.001). Residual conduction of left bundle branch was more frequent in group 2 (29% in group 1 vs. 52% in group 2, p = 0.03). CONCLUSIONS: Male gender, QRS duration greater than 140 ms, discordant LBBB, and residual conduction in the left bundle branch seem to be markers of reduced LVEF in patients with LBBB.

Relationship of platelet indices with acute stent thrombosis in patients with acute coronary syndrome.

INTRODUCTION: Despite major advances in stent technology and antithrombotic therapy, the development of stent thrombosis continues to be a major problem in patients who have undergone percutaneous coronary intervention (PCI). Although a few studies have investigated the relationship between early stent thrombosis and platelet activity, the relationship between acute stent thrombosis (AST) (within the first 24 h) and platelet indices is unclear. AIM: We investigated the relationship between AST development and platelet indices in acute coronary syndrome patients. MATERIAL AND METHODS: In our case-control study, 33 patients who underwent PCI with subsequent AST development and 59 patients without AST were selected by propensity analysis. We compared the clinical, angiographic, and laboratory data between the AST and control groups. RESULTS: Mean platelet volume (MPV) (p=0.002) and platelet distribution width (p=0.014) were significantly higher and platelet count (p=0.017) was significantly lower in the AST group. Logistic regression analyses showed that MPV was a significant independent predictor of AST (OR = 1.67; 95% CI: 1.11-2.51; p=0.013). In the ROC analyses, the cut-off value of MPV to detect AST was > 9.1 fl with a sensitivity of 90.9%, a specificity of 42.4%, a positive predictive value of 46.9% and a negative predictive value of 89.3% (AUC: 0.687, 95% CI: 0.582-0.780, p=0.001). CONCLUSIONS: Our study shows that baseline MPV predicts the development of AST in patients with ACS. Mean platelet volume therefore might be an easily accessible marker in the identification of patients at high risk for the development of AST.

Cardiac diastolic function is impaired at rest and worsens with exercise in otherwise healthy individuals with insulin resistance.

Insulin resistance (IR) is a pathophysiological condition and is associated with cardiovascular risk factors including heart failure. However, studies demonstrating myocardial abnormalities in the early phases of IR are limited. The aim of this study was to investigate myocardial function in otherwise healthy individuals with IR.Individuals with IR who were free of cardiovascular risk factors and healthy controls were included. Stress echocardiography with tissue Doppler imaging (TDI) was performed. Systolic and diastolic TDI waves were compared in both groups.A total of 77 individuals (51 with IR and 26 controls) were included in our study. The tissue early flow (e')/atrial contraction (a') ratio at rest was significantly lower in the IR group (P = 0.003). The annular early flow (E)/e' ratio, a predictor of left ventricular filling pressure, was similar in both groups at rest (P = 0.522). After exercise, e'/a' impairment became more prominent in the IR group (P < 0.001); whereas the E/e' ratio was also significantly lower (7.6 ± 1.8 versus 6.7 ± 0.9; P = 0.007) in the IR group.Myocardial involvement seems to occur in patients with IR, before the appearance of other cardiovascular risk factors. Exercise induced diastolic worsening may be a predictor of reduced compliance and increased ventricular stiffness. More detailed prospective studies are required for more precise results.

Predictors of anticoagulant treatment in patients with nonvalvular atrial fibrillation: results from atrial fibrillation in Turkey: epidemiologic registry.

The aim of the study was to assess the factors associated with the anticoagulation treatment in patients with atrial fibrillation (AF). A total of 2242 consecutive patients who had been admitted with AF on their electrocardiogram were included in the study. After excluding valvular AF, 1745 patients with nonvalvular AF were analyzed. Mean CHA2DS2-VASc score [cardiac failure, hypertension, age ≥ 75 (doubled), diabetes, stroke (doubled), vascular disease, age 65 -74 and sex category (female)], frequency of persistent/permanent AF, hypertension, diabetes mellitus (DM), stroke history, body mass index, and left atrial diameter were significantly higher in patients receiving anticoagulant therapy. Stroke history, persistent/permanent AF, hypertension, DM, age, heart failure, and left atrial diameter were independent predictors of warfarin prescription. Labile international normalized ratio was the only independent negative predictor of effective treatment with warfarin. In this study, we demonstrated that stroke history, persistent/permanent AF, hypertension, DM, and left atrial diameter were positive predictors, whereas advanced age and heart failure were negative predictors of oral anticoagulant use in patients with nonvalvular AF.

Increased ventricular pacing threshold levels in patients with high serum uric acid levels.

BACKGROUND: Permanent cardiac pacemakers (PCM) are accepted as the most effective treatment for symptomatic bradyarrhythmias. Serum uric acid (UA) levels are associated with various inflammatory markers, oxidative stress, and endothelial dysfunction. This study aimed to investigate the association between serum UA and ventricular pacing threshold (VPT) levels in patients who underwent permanent pacemaker implantation. MATERIALS AND METHODS: We retrospectively analyzed a total of 198 patients who underwent PCM implantation for indications such as symptomatic bradycardia without a reversible etiology and high-degree and complete atrioventricular block. RESULTS: VPT values were found to correlate with serum UA levels (r=0.591, p<0.001), high sensitivity C-reactive protein (hs-CRP) levels (r=0.505, p<0.001), and ventricular impedance (r=0.220, p=0.016). The serum UA levels and hs-CRP levels were also correlated (r=0.691, p<0.001). To identify independent risk factors for VPT values, a multivariate linear regression model was conducted, and serum UA levels (ß=0.361, p=0.001), hs-CRP levels (ß=0.277, p=0.012), and impedance values (ß=0.207, p=0.011) were found to be independent risk factors for VPT. CONCLUSION: In the present study, VPT values at the time of implantation and at the 30th day were increased in patients with high serum UA levels. To further extend the life of pacemakers, as well as other factors that affect threshold values, serum UA levels should be noted.

Influence of the Timing of Percutaneous Coronary Intervention on Clinical Outcomes in Non-ST-Elevation Myocardial Infarction.

BACKGROUND AND OBJECTIVES: We have intended to investigate the influence of the timing of invasive procedures on all-cause mortality, recurrent myocardial infarction (MI), re-hospitalization due to cardiac causes and left ventricular function over a 3-month period among patients with Non-ST-elevation myocardial infarction (NSTEMI). SUBJECTS AND METHODS: A total of 131 NSTEMI patients with moderate-high Thrombolysis in Myocardial Infarction risk scores, who had been admitted to our department between July 2011-December 2011 were included in our study. They had been randomized into 2 groups according to the timing of the percutaneous coronary intervention (PCI). Patient undergoing PCI in the first 24 hours of hospitalization were named the "Early Invasive Group" and those undergoing PCI between 24-72 hours of hospitalization were named the "Delayed Invasive Group". All patients were followed up for 3 months. RESULTS: Third month left ventricular ejection fraction (LVEF) values were higher in the early invasive group (59.9±6.0% vs. 54.1±8.7%; p<0.001). Recurrent MI rates were lower in the early invasive group (2.9% vs. 14.5%; p=0.016). Similarly, hospitalization rates due to cardiac events were lower in the early invasive group (8.7% vs. 30.6%; p=0.001). All cause mortality appeared to be lower in the early invasive group, although not to a statistically significant degree (0% vs. 4.8%; p=0.065). CONCLUSION: The early invasive strategy appears to be more effective for the reduction of recurrent MI, re-hospitalization due to cardiac events, and the preservation of 3rd month LVEF in patients with moderate-high risk NSTEMI when compared to a delayed invasive strategy.

Modified flower petal technique: a new technique for the treatment of Medina type 1.1.1 coronary bifurcation lesions.

OBJECTIVES: This study sought to propose a new technique for the treatment of Medina type 1.1.1 bifurcation lesions. BACKGROUND: Although there are many different 2-stent techniques, the optimal strategy for patients with Medina type 1.1.1 bifurcation lesions has not yet been determined. METHODS: The authors selected 30 patients who had Medina type 1.1.1 coronary bifurcation lesions. The most important characteristics of this new technique are complete coverage of the side branch (SB) ostium by stent struts and lower metallic burden at carina region. All procedures were performed using drug-eluting stents. All patients were followed up to 9 months after the intervention. Quantitative coronary angiography (QCA) analyses were performed for both the main and the side branches at baseline, after stent implantation, and at 9-month follow-up. RESULTS: Procedural success rate was 100%. Final kissing balloon inflation could be performed in all patients. There was no major adverse cardiac events during hospital stay. Clinical and angiographic QCA follow-up was available in 28 patients (93.4%). There was no death, myocardial infarction, or stent thrombosis at 9 months follow-up. In-stent restenosis requiring reintervention was noted at the SB ostium in only 1 patient. CONCLUSIONS: This new "modified flower petal" technique has several advantages for stent implantation of Medina type 1.1.1 bifurcation lesions over the available techniques: complete coverage of the SB ostium, lower metallic burden at the carina, and excellent immediate and midterm clinical outcomes.