Plasma osteopontin levels in prediction of prognosis in acute myocardial infarction.

OBJECTIVE: We sought to explain the clinical importance of the osteopontin (OPN) in the setting of acute ST-elevation myocardial infarction (STEMI). METHODS: Eighty consecutive patients (55 = 11 years, 12 women and 68 men) and sixty healthy control subjects were included in the study. In all patients, plasma OPN levels were assessed on admission and on the third day (peak value). Creatinine kinase (CK)/CK-myocardial band (MB), troponin I and N-terminal pro-brain natriuretic factor levels and echocardiographic findings were also recorded. Patients were classified into high and low OPN groups according to the median OPN value, and monitored for the occurrence of major adverse cardiovascular events (MACE). RESULTS: Patients with STEMI had higher OPN levels (23.8 [16.7-41.3] ng/ml) on admission than the control subjects (18.0 [11.3-31.5] ng/ml, P = 0.004).The third day value of OPN was significantly higher (39.2 [27.2-56.0] ng/ml) than the OPN level on admission (23.8 [16.7-41.3] ng/ml, P < 0.001). Admission and peak OPN levels were not correlated with CK/CK-MB, white blood cell counts, troponin I and the N-terminal pro-brain natriuretic factor. The plasma OPN levels were not correlated with left ventricular wall motion score index either. In the subgroups of infarct localization and reperfusion strategy, plasma OPN levels were similar. When the patients were compared according to the median OPN values, there were no differences in the occurrence of MACE between the high and low OPN groups. CONCLUSION: This study suggests, for the first time, that the plasma OPN level increases in the first hours of the acute STEMI; however, it could not be used as a prognostic biomarker of STEMI.

Myocardial injury due to lightning strike--a case report.

Lightning strike is a natural phenomenon with potentially devastating effects and represents one of the leading causes of cardiac arrest and death from environmental phenomena. Almost every organ system may be impaired as lightning passes through the human body taking the shortest pathways between the contact points. In this paper, the authors report a 38-year-old man who was injured by lightning, a typical example of ;;side splash,'' and had transient electrocardiographic changes.

Increased levels of soluble adhesion molecules E-selectin and P-selectin in patients with cardiac syndrome X.

The role of endothelial dysfunction and platelet activation in patients with cardiac syndrome X is controversial. The aim of this study was to investigate the plasma levels of circulating E- and P-selectin molecules in patients with syndrome X. The study included 21 patients with cardiac syndrome X (11 men and 10 women, mean age = 56 +/- 5 years) and 20 patients with significant coronary artery disease who had stable angina pectoris (11 men and 9 women, mean age = 60 +/- 8 years). Twenty-two age- and sex-matched subjects (12 men and 10 women, mean age = 58 +/- 8 years) undergoing diagnosis of atypical chest pain in whom coronary arteries were found normal and exercise test had no signs of ischemia served as the control group. Syndrome X was defined as presence of typical chest pain on exertion or at rest with positive exercise test and angiographically normal epicardial coronary arteries with no evidence of coronary spasm after intracoronary infusion of ergonovine maleate. The mean plasma concentrations of P-selectin were significantly elevated both in patients with coronary artery disease and syndrome X as compared with control subjects (49.15 +/-7.47 and 42.80 +/- 8.93 vs 22.63 +/-6.47 ng/mL, p < 0.001). Similarly, both patients with coronary artery disease and syndrome X had higher plasma concentrations of E-selectin than the control group (78.85 +/- 16.69 and 68.38 +/- 15.30 vs 36.43 +/- 4.72 ng/mL, p < 0.001). In conclusion, patients with syndrome X had increased plasma concentrations of soluble adhesion molecules, E-selectin and P-selectin, reflecting an ongoing chronic inflammation involved with endothelial dysfunction and enhanced platelet activation/damage in this setting.

Relationship between control of ventricular rate in atrial fibrillation and systemic coagulation activation in patients with mitral stenosis.

BACKGROUND AND AIM OF THE STUDY: Systemic thromboembolism is a major complication in patients with mitral stenosis (MS), especially in those who have atrial fibrillation (AF). It has been suggested that systemic coagulation activity may be increased in these patients. The study aim was to investigate the relationship between control of ventricular rate and systemic coagulation factors in patients with MS and AF by measuring plasma levels of prothrombin fragment (PF) 1+2, thrombin-antithrombin III complex (TAT) and plasminogen activator inhibitor-1. METHODS: Fifty-four consecutive patients with moderate to severe MS and AF were included in the study. Patients with resting heart rates < 100 beats per min were considered as having a controlled ventricular response rate (group A; n = 28) and those with > 100 beats per min as an uncontrolled ventricular response rate (group B; n = 26). RESULTS: Group A patients had a lower mean mitral gradient and pulmonary artery pressure than group B patients (11 +/- 6 versus 15 +/- 5 and 35 +/- 7 versus 39 +/- 8; p < 0.05, respectively). Plasma concentrations of PF 1+2 (4.17 +/- 2.1 versus 2.95 +/- 1.21; p < 0.01) and TAT III (4.61 +/- 1.75 versus 3.12 +/- 1.01; p < 0.01) were elevated in group B compared with group A. Similarly, group B patients had higher plasminogen activator inhibitor-1 levels than group A patients (7.87 +/- 3.8 versus 5.8 +/- 2.9; p < 0.05). A significant correlation was found between heart rate and plasma PF 1+2 and TAT levels. Multiple logistic regression analysis revealed that heart rate and mean mitral gradient were independent predictors of systemic coagulation activation. CONCLUSION: Besides contributing towards hemodynamic and symptomatic relief, the control of AF rate in MS patients induces a drastic decline in coagulation activation, and may also reduce the incidence of thromboembolism.

Correlation between infarct-related coronary artery patency and predischarge electrocardiographic patterns in patients with first anterior myocardial infarction who received thrombolytic therapy.

The aim of this study was to investigate the correlation between the ST-segment and T-wave patterns in predischarge electrocardiogram and patency of left anterior descending coronary artery in patients with a first anterior myocardial infarction (AMI). One hundred and fifty-six of 175 consecutive patients who were admitted to our clinic between January 2000 and September 2002 due to a first episode of transmural AMI and who received thrombolytic therapy were enrolled. Coronary angiography was performed by the Judkins method on the 6th-10th day after the acute infarction. The corrected TIMI frame count (CTFC) was estimated according to the previously described method. According to the combination of the ST-segment and T-wave morphology on the day (6-10) of cardiac catheterization, patients were classified into four groups: group A, ST elevation <<0.1 mV and negative T waves; group B, ST elevation >or=0.1 mV and negative T waves; group C, ST elevation <<0.1 mV and positive T waves; and group D, ST elevation >or=0.1 mV and positive T waves. Of the 99 patients with negative T waves, 47 (48%) had CTFC or=40-100, and 5 (5%) CTFC >>100. Of the 57 patients with positive T waves, CTFC was or=40-100 in 11 (19%), and >>100 in 15 (26%) ( P << 0.001). From the 76 patients with an isoelectric ST segment, 38 (50%) had CTFC or=40-100, and 1 (1%) CTFC >>100. Of the 80 patients with an elevated ST segment, 23 (29%) had CTFC or=40-100, and 19 (23%) CTFC >>100 ( P << 0.001). Use of the combination of two electrocardiographic parameters (ST segment and T waves) also indicated that there were significant differences between groups A and D, and groups B and D ( P << 0.001 and P << 0.05, respectively). Development of an isoelectric ST segment with negative T waves may indicate a better degree of reperfusion after AMI. In contrast, patients in whom ST-segment elevation and positive T waves remain at discharge from the coronary care unit have a higher probability of a nonpatent left anterior descending artery.

Increased blood coagulation and platelet activation in patients with infective endocarditis and embolic events.

BACKGROUND: Inflammation-induced procoagulant changes and alterations in platelet activity appear to play an important role in thromboembolic complications of infective endocarditis (IE). HYPOTHESIS: The aim of this study was to investigate systemic coagulation activity, fibrinolytic capacity, and platelet activation in patients with IE with and without embolic events by measuring the plasma levels of prothrombin fragment 1+2 (PF1+2), thrombin-antithrombin III complex (TAT), plasminogen activator inhibitor-1 (PAI-1), beta-thromboglobulin (beta-TG), and platelet factor 4 (PF4), respectively. METHODS: The study included 76 consecutive patients (female = 55, male = 21, mean age 26 years, range 8-64 years) with definite IE according to the Duke criteria; of these, 13 (17.1%) had embolic events. RESULTS: Plasma concentrations of PF1+2 (3.2 +/- 1.3 vs. 1.7 +/- 0.7 and 1.4 +/- 0.7 nmol/l, p < 0.001, respectively) and TAT (7.3 +/- 1.5 vs. 2.9 +/- 1.2 and 2.2 +/- 1.1 ng/ml, p < 0.001, respectively) were elevated in patients with embolic events compared with patients without embolic events and control subjects. Similarly, patients with embolic events had increased plasma levels of beta-TG (63.3 +/- 10.9 vs. 33.1 +/- 11.6 and 19.1 +/- 10.6 ng/ml, p < 0.001, respectively) and PF4 (106.0 +/- 28.7 vs. 50.3 +/- 16.7 and 43.0 +/- 15.8 ng/ml, p < 0.001, respectively) compared with those without embolic events and the control group. Embolic patients also had higher PAI-1 levels than nonembolic patients and healthy subjects (14.4 +/- 6.4 vs. 8.6 +/- 5.9 and 5.4 +/- 4.3 ng/ml, p = 0.002, respectively). CONCLUSION: Patients with IE and with subsequent thromboembolism have increased systemic coagulation activation, enhanced platelet activity/damage, and impaired fibrinolysis. The resulting imbalance produces a sustained hypercoagulable state, which contributes to the increased risk of thromboembolic events in this particular group.

Polymyositis complicated with complete atrioventricular block--a case report and review of the literature.

A 35-year-old woman, diagnosed with polymyositis about 5 years before was admitted to the authors' clinics with syncope attack due to complete atrioventricular (AV) block. Progression of left bundle branch block to complete AV block despite all immune-suppressive treatment, and rarity of this complication in patients with polymyositis prompted the authors to report this case.

Relationship between myocardial viability and the predischarge electrocardiographic pattern in patients with first anterior wall acute myocardial infarction.

BACKGROUND: The assessment of residual viability in the infarcted area after an acute myocardial infarction is relevant to subsequent management and prognosis. OBJECTIVE: The aim of this study was to investigate the correlation between myocardial viability after an acute anterior myocardial infarction (AMI) as assessed by low dose dobutamine stress echocardiography (LDDSE) and the electrocardiographic patterns of ST segment and T wave abnormalities at the end of the first week of the acute event. METHODS: Sixty-nine consecutive patients (51 men, 18 women, mean age+/-standard deviation=57+/-11 years) who admitted to our clinic due to a first episode of transmural AMI were included in this study. Two-dimensional echocardiography was performed to all patients during rest and low dose dobutamine administration at the end of the first week of admission (7+/-2 days). Patients were classified into four groups according to ST segment and T wave morphology: group A, ST elevation < or =0.1 mV and negative T waves; group B, ST elevation < or =0.1 mV and positive T waves; group C, ST elevation > or =0.1 mV and negative T waves and group D, ST elevation > or =0.1 mV and positive T waves. RESULTS: Myocardial viability was detected more often in patients with isoelectric ST segments (22/24, 92%) than those with elevated ST segments (21/45, 47%) (P<0.001). Similarly patients with negative T waves had myocardial viability more frequently compared to those with positive T waves (32/45, 71% vs. 11/24, 46%, P<0.01). Seventeen (94%) of 18 patients in group A and 5 (83%) of six patients in group B had viable myocardium (P>0.05). Myocardial viability was found in 15 (56%) of 27 patients in group C and six (33%) of 18 patients in group D (P<0.01). As a marker of viable myocardium, isoelectricity of ST segment was specific (92%) but only moderately sensitive (51%), with a 92% positive predictive accuracy and a poor (53%) negative predictive value. T wave negativity was less specific but more sensitive than isoelectricity of ST segment for myocardial viability. CONCLUSION: The presence of isoelectric ST segment and negative T wave indicates a high probability of myocardial viability. However, absence of these electrocardiographic patterns does not exclude the presence of viable myocardium.

Differential diagnosis and clinical course of amiodarone-induced thyroid dysfunction.

BACKGROUND: Amiodarone is an iodine-rich drug widely used for the management of various arrhythmias, but its clinical utility is usually limited by the high frequency of numerous side effects, most frequently disturbance of thyroid function. MATERIAL/METHODS: The present study presents the laboratory tests, color flow Doppler sonography (CFDS) findings, treatment and prognosis of 22 patients with amiodarone-induced thyroid dysfunction. RESULTS: Eleven patients developed amiodarone- induced thyrotoxicosis (AIT), ten developed amiodarone-induced hypothyroidism (AIH) and one patient first developed AIT, followed by AIH. Age, amiodarone doses, duration of amiodarone treatment and discontinuation of amiodarone were similar in the patients with AIT and AIH. AIT was found more commonly in male patients, AIH in female patients. Color flow Doppler sonographic examination was performed in all patients with AIT to differentiate type 1 and 2 AIT. In ten patients, CFDS demonstrated increased glandular vascularity, diagnostic for type 1 AIT. CONCLUSIONS: This paper presents patients with AIT treated successfully with propylthiouracil or prednisolone after developing thyroid dysfunction as a consequence of amiodarone use. The role of thyroid Doppler in managing these patients is emphasized.

[Classification of patients with complete atrioventricular block according to etiological, demographic and clinical features and pacemaker needs]. / Atriyoventriküler Tam Bloklu Hastalarin Etiyolojik, Demografik, Klinik Ozellikleri Ile Pacemaker Ihtiyaçlarina Göre Siniflandirilmalari.

OBJECTIVE: Complete atrioventricular (AV) block is a rhythm disorder that can result from various causes. The aim of this study was to define etiological factors, clinical features, pacemaker needs, in-hospital mortality rates and factors affecting these parameters in the patients with complete AV block. METHODS: For this aim, 191 consecutive patients admitted to the hospital with complete AV block or who developed AV block during their hospital course between January 1999-September 2002 were included into the study. RESULTS: The most common underlying cause of AV block was found to be the ischemia, which was followed by unknown etiology and iatrogenic complete AV block. The most common cause of in-hospital mortality was ischemic (especially acute) heart disease. No etiological factor for complete AV block was found in most of symptomatic patients presented with syncope. In patients with ischemic complete AV block, mortality and syncope rates were found to be high, especially in patients with multivessel disease. Permanent pacemaker was implanted in 76 of 191 patients with complete AV block and the significant portion of these patients were those without an etiological cause. CONCLUSION: Thus, it is revealed that factors affecting mortality in patients with complete AV block are acute myocardial infarction and age while other clinical parameters and pacemaker implantation had no effects on mortality.

Effects of slow coronary artery flow on QT interval duration and dispersion.

BACKGROUND: The coronary slow-flow phenomenon is an angiographic phenomenon characterized by delayed opacification of vessels in the absence of any evidence of obstructive epicardial coronary disease. Several studies have demonstrated myocardial ischemia in patients with slow coronary artery flow. In the present study, we aimed at evaluating the effects of slow coronary artery flow on QT interval duration and QT dispersion as a possible indicator of increased risk for ventricular arrhythmias and sudden cardiac death. METHODS: The study population included 49 patients with angiographically proven normal coronary arteries and slow coronary flow in all three coronary vessels (group I, 33 males, 16 females, mean age = 48 +/- 9 years), and 71 patients with angiographically proven normal coronary arteries without associated slow coronary flow (group II, 47 males, 24 females, mean age = 50 +/- 8 years). Coronary flow rates of all subjects were documented by thrombolysis in myocardial infarction frame count (TIMI frame count). QT interval duration and QT dispersion of all subjects were measured on the standard 12-lead electrocardiogram. RESULTS: There was no statistically significant difference between the two groups in respect to age, gender, presence of hypertension, and diabetes mellitus. There was a significant difference between the two groups in respect to the presence of cigarette smoking, typical angina, and positive exercise test results. TIMI frame counts of group I patients were significantly higher than those of group II patients for all three coronary arteries (P < 0.001). Maximum corrected QT interval (QTcmax) of group I did not differ from the QTcmax of group II (P > 0.05). However, minimum corrected QT interval (QTcmin) of group I was significantly lower than that for group II (P = 0.008). Consequently, corrected QT dispersion (QTcd) in group I was found to be significantly higher than in group II (P < 0.001). CONCLUSION: QTcd, indicating increased risk for ventricular arrhythmias and cardiovascular mortality, was found to be significantly higher in patients with slow coronary artery flow. However, further long-term prospective studies should be carried out to establish the significance of QTcd as a risk factor for ventricular arrhythmias and subsequent sudden cardiac death in patients with slow coronary artery flow.

Effect of infective endocarditis on blood coagulation and platelet activation and comparison of patients with to those without embolic events.

Inflammation-induced procoagulant changes and alterations in platelet activity appear to play an important role in thromboembolic complications of infective endocarditis (IE). The aim of this study was to investigate systemic coagulation activity, fibrinolytic capacity, and platelet activation in IE patients with and without embolic events by measuring the plasma levels of prothrombin fragment 1 + 2, thrombin-antithrombin III complex, plasminogen activator inhibitor-1, beta-thromboglobulin, and platelet factor 4. The study included 76 consecutive patients with definite IE according to the Duke criteria. Among them, 13 (17.1%) had major embolic events. Plasma concentrations of prothrombin fragment 1 + 2 (3.2 +/- 1.3 vs 1.7 +/- 0.7 and 1.4 +/- 0.7 nmol/L, p <0.001, respectively) and thrombin-antithrombin (7.3 +/- 1.5 vs 2.9 +/- 1.2 and 2.2 +/- 1.1 ng/ml, p <0.001, respectively) were elevated in patients with embolic events compared with both patients without embolic events and control subjects. Similarly, patients with embolic events had increased plasma levels of beta-thromboglobulin (63.3 +/- 10.9 vs 33.1 +/- 11.6 and 19.1 +/- 10.6 ng/ml, p <0.001, respectively) and platelet factor 4 (106.0 +/- 28.7 vs 50.3 +/- 16.7 and 43.0 +/- 15.8 ng/ml, p <0.001, respectively) compared with those without embolic events and the control group. Embolic patients also had higher plasminogen activator inhibitor-1 levels than both nonembolic patients and healthy subjects (14.4 +/- 6.4 vs 8.6 +/- 5.9 and 5.4 +/- 4.3 ng/ml, p = 0.002, respectively). In conclusion, IE patients with subsequent thromboembolism have increased systemic coagulation activation, enhanced platelet activity/damage, and impaired fibrinolysis. The resulting imbalance produces a sustained hypercoagulable state that may contribute to the increased risk of thromboembolic events in this particular group.

Aortic valve calcification: its significance and limitation as a marker for coronary artery disease.

Aortic valve calcification (AVC) is correlated with atherosclerotic risk factors; however, its significance remains largely unknown. The aim of this study was to investigate whether AVC detected by transthoracic echocardiography can be a useful marker for the identification of significant coronary artery disease (CAD), particularly in elderly patients. The study included 432 consecutive patients with suspected CAD who were admitted for the first time for coronary angiography. Two-dimensional transthoracic echocardiography and selective coronary angiography were performed in all patients. Aortic valve calcification was defined as bright dense echoes of > 1 mm on one or more cusps and decreased mobility of the involved cusp. Aortic valve calcification was detected in 64 of the 337 patients with significant CAD, but only in 9 of 95 cases with normal or mildly stenotic coronary arteries (19% vs 9%, p < 0.001). The severity of coronary artery disease (defined as the number of obstructed vessels) was not related to the presence of AVC (p > 0.05). Stepwise multiple logistic regression analysis of the study patients revealed only age (p=0.003, odds ratio= 1.56) and AVC (p<0.001, odds ratio = 2.03) as independent predictors of CAD. When the study population was divided into two groups as those below (n = 338) and above (n = 94) 75 years old, AVC failed to be a predictor of CAD in those >75 years old (p > 0.05, odds ratio = 0.8) while it remained the most significant predictor of CAD (p<0.001, odds ratio=2.19 in patients aged <75 years. In conclusion, detection of AVC by transthoracic echocardiography may be a useful noninvasive marker for identification of significant CAD in patients younger than 75 years old. Its clinical usefulness is limited in elderly patients.