Predictive value of PRECISE-DAPT score for long-term all-cause mortality in atrial fibrillation patients with non-ST-elevation myocardial infarction.

Introduction: Atrial fibrillation (AF) may co-exist in patients with non-ST-elevation myocardial infarction (NSTEMI). In patients with NSTEMI, AF should therefore be regarded as an important risk factor irrespective of its presentation. To predict outcomes in AF patients presenting with NSTEMI, early risk stratification can help to identify the patients with a possible poor long-term prognosis. The development of the PRECISE-DAPT score aimed to predict the risk of bleeding in patients who underwent stent implantation and received dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI), providing a valuable tool for assessing bleeding risk in this specific patient population. Aim: To assess the performance of the PRECISE-DAPT score in predicting long-term prognosis in AF patients with NSTEMI. Material and methods: Five hundred and twenty-six consecutive AF patients presenting with NSTEMI were included in the present study. The PRECISE-DAPT score was calculated in each case and evaluated for the association of increased mortality in the study population, who survived in-hospital but died in the long term. Results: All-cause mortality deaths occurred in 278 (52.6%) patients. Higher PRECISE-DAPT score, shorter duration of P2Y12 inhibitor therapy, decreased left ventricular ejection fraction (LVEF), and a history of diabetes mellitus (DM) were all associated with an increased risk of all-cause mortality in the multivariable logistic regression model. Conclusions: High PRECISE-DAPT score was associated with higher long-term all-cause mortality in AF patients presenting with NSTEMI.

The relation of polymer structure of stent used in patients with acute coronary syndrome revascularized by stent implantation with long-term cardiovascular events.

INTRODUCTION: Drug-eluting stents (DES) have revolutionized percutaneous coronary intervention (PCI) by improving event-free survival compared to older stent designs. However, early-generation DES with polymer matrixes have raised concerns regarding late stent thrombosis due to delayed vascular healing. To address these issues, biologically bioabsorbable polymer drug-eluting stents (BP-DES) and polymer-free drug-eluting stents (PF-DES) have been developed. AIM: The aim of the present study is to evaluate and compare the long-term effects of different stent platforms in patients with acute coronary syndrome (ACS) undergoing PCI. MATERIAL AND METHODS: We conducted a retrospective, observational study involving 1192 ACS patients who underwent urgent PCI. Patients were treated with thin- strut DP-DES, ultra-thin strut BP-DES, or thin-strut PF-DES. The primary endpoint was a composite of cardiac death, target vessel myocardial infarction (TVMI), and clinically driven target lesion revascularization (CITLR) at 12 months and 4 years. RESULTS: The baseline demographics and clinical characteristics of patients in the three stent subgroups were similar. No significant differences were observed in target lesion failure (TLF), cardiac mortality, TVMI, and stent thrombosis (ST) rates among the three subgroups at both 12 months and 4 years. However, beyond the first year, the rate of CITLR was significantly lower in the ultra-thin strut BP-DES subgroup compared to thin-strut DP-DES, suggesting potential long-term advantages of ultra-thin strut BP-DES. Additionally, both ultra-thin strut BP-DES and thin-strut PF-DES demonstrated lower ST rates after the first year compared to thin-strut DP-DES. CONCLUSION: Our study highlights the potential advantages of ultra-thin strut BP-DES in reducing CITLR rates in the long term, and both ultra-thin strut BP-DES and thin-strut PF-DES demonstrate lower rates of ST beyond the first year compared to thin-strut DP-DES. However, no significant differences were observed in overall TLF, cardiac mortality and TVMI rates among the three stent subgroups at both 12 months and 4 years.

The effect of urgent blood pressure reduction on left atrial strain in patients with hypertensive attack : Blood pressure lowering affects LA strain.

BACKGROUND: Left atrial (LA) strain is a robust measure of LA function and is a useful parameter to assess left ventricular filling pressure. While initially considered as a "load-independent" parameter of LA function, later studies have found that acute changes in LA preload may affect LA reservoir and contractile strains. Acute alterations in blood pressure (BP) induces a change in left ventricular (LV) filling pressure without imposing a volume load, thus providing an opportunity to assess the effects of the change in LA afterload on LA mechanics. This study aims to understand the effect of acute BP changes on LA strain. METHODS: A total of 40 patients admitted to the emergency department with hypertensive urgency were included. All patients underwent a comprehensive echocardiographic examination including measurement of LA reservoir, conduit and contractile strains. A repeat set of measurements were obtained after BP lowering. RESULTS: Average drop in mean BP following intervention was 18.1 ± 5.4%. LV end-systolic and end-diastolic volumes, as well as maximum and minimum LA volumes were decreased significantly after BP reduction. The absolute increases in reservoir and contractile strains were 2.3 ± 4.7% (7.9% ± 13.8% relative to baseline) and 2.5 ± 3.3% (13.5 ± 19.0% relative to baseline), respectively, with both changes being statistically significant (p = 0.003 for reservoir and p < 0.001 for contractile strains). There were no significant changes in conduit strain after BP intervention (p = 0.79). The change in both LA reservoir and contractile strains were more evident in those with a previous diagnosis of hypertension and those with a smaller degree of change in mean BP after intervention. CONCLUSION: In patients with an acute hypertension, lowering BP leads to an acute improvement in LA reservoir and contractile strains. Thus, acute changes in systemic BP should be considered when LA mechanics are evaluated.

Successful treatment of patent ductus arteriosus accompanying right-sided aortic arch and aberrant left subclavian artery: a case report.

Background: The coexistence of a right-sided aortic arch (RAA), an aberrant left subclavian artery (ALSA), and a patent ductus arteriosus (PDA) is a rarely seen vascular ring anomaly. There is currently no general guideline consensus on the management and follow-up of this congenital defect, posing a challenge to the clinicians. At this point, the heart team plays a critical role in the management of the disease. Case summary: In the present case, a 25-year-old male patient was presented to the outpatient clinic with dyspnoea and fatigue. A transthoracic echocardiography revealed PDA with a left-to-right shunt. To evaluate the anatomy thoroughly, a thoracic computed tomographic angiography was performed and showed PDA accompanying ALSA and RAA. The patient was evaluated by the Heart Team, and a percutaneous closure of PDA was recommended due to signs of left ventricular volume overload. The closure was successfully performed with Amplatzer vascular plug II. At follow-up, the patient was free of symptoms. Discussion: Clinicians should be aware of the potential concomitant lesions during the diagnostic work-up. In selected patients, percutaneous closure of PDA may be the first-line therapy in experienced centres.

Predictive value of the age, creatinine and ejection fraction score in patients undergoing primary percutaneous coronary intervention with bail-out tirofiban therapy.

INTRODUCTION: In patients who have undergone interventional cardiac procedures, the risk of bleeding is higher than in patients who received conservative treatment due to multiple medications and comorbidities. AIM: This study aimed to evaluate the usefulness of the age, creatinine and ejection fraction (ACEF) score for predicting bleeding events and to compare short- and long-term clinical outcomes according to the ACEF score in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) with bail-out tirofiban therapy (BOTT). MATERIAL AND METHODS: A total of 2,543 patients were included and divided into three groups according to the following ACEF score tertiles: T1 (ACEFlow ≤ 1.033), T2 (1.033 < ACEFmid ≤ 1.371), and T3 (ACEFhigh > 1.371). The main outcomes measured were the incidence rates of relevant bleeding events and mortality within 30 days and 3 years after the procedure. RESULTS: A total of 73 (2.9%) patients had Bleeding Academic Research Consortium bleeding events of grades 3, 4 or 5 and 104 (4%) patients died in a 30-day period. The ACEF score was effective at predicting 30-day bleeding (area under the receiver operating characteristic curve (AUC): 0.658, 95% confidence interval (CI): 0.579-0.737; p < 0.001), 30-day mortality (AUC = 0.701, 95% CI: 0.649-0.753; p < 0.001) and 3-year mortality (AUC = 0.778, 95% CI: 0.748-0.807; p < 0.001) events. Considering the ACEF score tertiles, T3 patients presented greater 30-day bleeding (1.6%, 2.8% and 4.1%; odds ratio (OR) = 2.56, 95% CI: 1.37-4.80), 30-day mortality (1.7%, 3.5% and 7.1%; OR = 4.53, 95% CI: 2.51-8.18) and 3-year mortality (6.4%, 11% and 19.8%; hazard ratio = 3.56, 95% CI: 2.58-4.91) risks. CONCLUSIONS: The ACEF score is a user-friendly tool with excellent predictive value for bleeding events and mortality in patients undergoing pPCI with BOTT.

Differences in clinical and echocardiographic variables and mortality predictors among older patients with pulmonary embolism.

BACKGROUND: An increase in short-term mortality can be found among older patients with hemodynamically stable acute pulmonary embolism (APE) who have signs of right ventricular (RV) dysfunction. AIMS: This study was designed to assess whether any difference exists among clinical, laboratory, electrocardiography and echocardiography parameters between older and younger patients diagnosed with APE. METHODS: The study sample included a total of 635 patients with confirmed APE who were divided into two groups of older (65 years and older) and younger (younger than 65 years) individuals. Comparisons were performed between these groups in terms of clinical, predisposing factors and laboratory, electrocardiographic and echocardiographic parameters. RESULTS: Analyses of 295 (46.4%) older and 340 (53.6%) younger patients diagnosed with APE were performed. Female sex, Pulmonary Embolism Severity Index score and baseline creatinine levels were higher in the older group. Also, the frequency of atrial fibrillation, RV outflow tract parasternal long-axis proximal diameter, RV end-diastolic diameter (RV-EDD) basal (apical four-chamber) and RV systolic pressure were significantly greater in older patients with APE. A total of 30 (4.7%) deaths were observed during the in-hospital period [21 (7.1%) older vs 9 (2.6%) younger patients; p < 0.01]. In the multivariate logistic regression analysis, age, white blood cell count (WBC), left ventricular ejection fraction (LVEF), RV-EDD basal and tricuspid annular plane systolic excursion (TAPSE) of less than 16 mm were found to be independently associated with in-hospital mortality. CONCLUSION: Older patients might experience greater rates of RV dilatation, RV dysfunction and atrial fibrillation during APE. In addition to age; elevated WBC, low LVEF, increased RV-EDD basal and TAPSE of less than 16 mm were independent predictors of mortality among study population.

Clinical usefulness of epicardial adipose tissue in patients with high-intermediate pre-test probability for coronary artery disease.

BACKGROUND: Epicardial adipose tissue (EAT) is thought to be associated with the extension and severity of coronary artery disease (CAD), and echocardiographic measurement of EAT thickness is considered to be a possible cardiovascular risk indica-tor. The European Society of Cardiology Task Force recommends further non-invasive testing in patients with an intermediate pre-test probability (PTP) for the diagnosis of CAD. AIM: We sought to evaluate the clinical usefulness of performing EAT measurements in patients with a high-intermediate PTP. METHODS: Patients referred to an outpatient clinic with stable chest pain symptoms, with PTP for CAD between 66% and 85%, were included in the study. Echocardiographic measurement of the EAT was identified as the echo-free space between the outer wall of the myocardium and the visceral layer of the pericardium. Single-photon emission computed tomography (SPECT) was performed in all patients. The diagnosis of CAD was based on the presence of reversible perfusion defects on SPECT. RESULTS: A total of 126 patients (76 men, 60.3%) with a mean age of 65.3 ± 9.1 years were recruited. The EAT thickness was 7.3 ± 0.7 mm in patients with positive SPECT and 6.2 ± 0.6 mm in patients with negative SPECT (p < 0.001). Multivariable analysis revealed higher rates of positive SPECT in patients with higher EAT (odds ratio [OR] 9.80; 95% confidence interval [CI] 3.72-25.79; p < 0.001), and receiver operating characteristic curve analysis showed that the greatest specificity was obtained when the cut-off value of EAT thickness was 6.75 mm (sensitivity 76%; specificity 74%). CONCLUSIONS: In patients with high-intermediate PTP, EAT is a useful measurement that may assist in risk stratification.

Left ventricular mechanics in isolated mild mitral stenosis: a three dimensional speckle tracking study.

In a fraction of patients with mild mitral stenosis, left ventricular systolic function deteriorates despite the lack of hemodynamic load imposed by the dysfunctioning valve. Neither the predisposing factors nor the earlier changes in left ventricular contractility were understood adequately. In the present study we aimed to evaluate left ventricular mechanics using three-dimensional (3D) speckle tracking echocardiography. A total of 31 patients with mild rheumatic mitral stenosis and 27 healthy controls were enrolled to the study. All subjects included to the study underwent echocardiographic examination to collect data for two- and three-dimensional speckle-tracking based stain, twist angle and torsion measurements. Data was analyzed offline with a echocardiographic data analysis software. Patients with rheumatic mild MS had lower global longitudinal (p < 0.001) circumferential (p = 0.02) and radial (p < 0.01) strain compared to controls, despite ejection fraction was similar for both groups [(p = 0.45) for three dimensional and (p = 0.37) for two dimensional measurement]. While the twist angle was not significantly different between groups (p = 0.11), left ventricular torsion was significantly higher in mitral stenosis group (p = 0.03). All strain values had a weak but significant positive correlation with mitral valve area measured with planimetry. Subclinical left ventricular systolic dysfunction develops at an early stage in rheumatic mitral stenosis. Further work is needed to elucidate patients at risk for developing overt systolic dysfunction.

An unexpected complication of acute pancreatitis: Intra-cardiac thrombus.

Left atrial thrombus after acute pancreatitis (AP) is a rare clinical statement. Because of induction of systemic prothrombotic process by AP; some patients with underlying risk factors may develop an intra-cardiac thrombus. We present a 53years-old-woman with moderate mitral stenosis and atrial fibrillation. However the patient was under warfarin treatment, she developed a big left atrial big thrombus which was originated from left atrial appendage after she was suffered from AP.

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.

Congenital absence of the pericardium: a rare cause of right ventricular dilatation and levoposition of the heart.

Congenital absence of the pericardium is a rare cardiac defect with variable clinical presentations and is usually discovered incidentally. The pathology may lead to serious complications such as incarceration of cardiac tissue, myocardial ischemia, aortic dissection or valvular insufficiency. Diagnosis is not difficult so long as some tips are remembered. We present the cases of two patients with congenital absence of left pericardium.

Aortic root abscess complicated by fistulization in a young patient with bicuspid aortic valve.

Aortic root abscess is a relatively common complication of aortic valve endocarditis. However, aortic root abscess and formation of a fistula from the aortic root to the right ventricular outflow tract in the setting of a native bicuspid aortic valve (BAV) is a rare event. We present consecutive echocardiographic images of unruptured periaortic abscess and fistulization of it to the right ventricle in 24 hours, in a patient with BAV and fever of unexplained origin.

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.

The relationship between endothelial nitric oxide synthase gene polymorphism (T-786 C) and coronary artery disease in the Turkish population.

Previous studies revealed that there were various mutations on endothelial nitric oxide synthase (eNOS) gene and these mutations might be a risk factor for coronary artery disease (CAD), myocardial infarction (MI), and hypertension (HT). In this study, we aimed to investigate the relationship between eNOS gene polymorphism (T-786 C) and coronary artery disease in the Turkish population. Two hundred and eleven unrelated individuals (152 male, 59 female, mean age 59 years, range 27-85) whose angiographic examinations were performed in our hospital were enrolled into the study; 159 of these had angiographically determined coronary artery lesions (>or=50% stenosis at least in one vessel). Fifty-two individuals were free of coronary artery disease on their coronary angiography. The Gensini scoring system was used to determine the severity of the CAD. The polymerase chain reaction (PCR) method was used for genotyping the individuals. To determine the independent risk factors for coronary artery disease, multivariate logistic regression analysis was used. The variant distribution of the T-786 C polymorphism was as follows. For all individuals: TT 94 (44.5%), TC 88 (41.7%), CC 29 (13.8%); in CAD patients: TT 63 (39.6%), TC 73 (45.9%), CC 23 (14.5%); and in normal individuals: TT 31 (59.6%), TC 15 (28.8%), CC 6 (11.5%). There was a statistically significant difference in the variant distribution between CAD and normal individuals (P<0.05). On the other hand, when we compared the frequency of the at-least-one-C-allele carriers (CC+TC, dominant model) and TT homozygous, those with at least one C allele were more prevalent in CAD patients. The results were as follows. In coronary artery disease patients: CC+TC 96 (60.4%), TT 63 (39.6%); in normals: TC+CC 21 (40.4%), TT 31 (59.6%) (P<0.01). When we compared the allele distribution (T vs C, additive model) between CAD patients and normal controls, the results were as follows: T 0.625 vs 0.740, C 0.375 vs 0.260; there was also a statistically significant association between CAD and C allele (P<0.05). When we compared the means of the Gensini scores between each genotype of the T-786 C mutation, there was a statistically significant difference. The results were TT (48.6+/-37.3, median 43.0), TC (55.4+/-41.2, median 41.0), CC (77+/-43.6, median 80.0) (P<0.05). Multivariate logistic regression analysis revealed that C-dominant (CC+TC) individuals had 2.9-fold more likelihood to suffer from CAD (odds ratio: 2.902; confidence interval: 1.272-6.622) (P<0.05). We conclude that the T-786 C polymorphism of eNOS gene might be a risk factor for coronary artery disease in the Turkish population.

A case of prosthetic mitral valve Brucella endocarditis complicated with torsades de pointes.

Brucella endocarditis is a zoonosis transmitted by contaminated dairy products. Endocarditis is a rare complication of brucellosis and mainly the aortic valve is infected. We present the case of a female patient with prosthetic mitral valve endocarditis associated with QT prolongation and torsades de pointes. Transesophageal echocardiography revealed vegetation on both anterior and posterior mitral annulus. She was seropositive with Brucella agglutination titers of up to 1/320. The QT interval was markedly prolonged upon admission (QTc 530 ms). She experienced torsades de pointes several times. She underwent reoperation under an appropriate antibiotic regimen. She continued on triple antibiotic therapy for 12 months. She is now well and free of symptoms.