In-hospital and short-term predictors of mortality in patients with intermediate-high risk pulmonary embolism.

Introduction: The aim of this study was to evaluate the in-hospital and short-term predictive factors of mortality in intermediate-high risk acute pulmonary embolism (PE) patients with right ventricle (RV)dysfunction and myocardial injury. Methods: In this retrospective study, the medical records of 187 patients with a diagnosis of intermediate high risk acute PE were evaluated. A contrast-enhanced multi-detector pulmonary angiography was used to confirm diagnosis in all cases. All-cause mortality was determined by obtaining both in hospital and 30 days follow-up data of patients from medical records. Results: During the in-hospital stay (9.5±4.72 days), 7 patients died, resulting in an acute PE related in-hospital mortality of 3.2%. Admission heart rate (HR), (Odds ratio (OR), 1.028 95% Confidence interval (CI), 0.002-1.121; P = 0.048) and blood urea nitrogen (BUN) (OR, 1.028 95% CI, 0.002-1.016; P = 0.044) were found to be independent predictors for in-hospital mortality in a multi variate logistic regression analysis. In total, 32 patients (20.9%) died during 30 days follow-up.The presence of congestive heart failure (OR, 0.015, 95%CI, 0.001-0.211; P = 0.002) and dementia (OR, 0.029, 95%CI,0.002-0.516; P = 0.016) as well as low albumin level (OR, 0.049 95%CI, 0.006-0.383; P = 0.049) were associated with 30 days mortality. Conclusion: HR and BUN were independent predictors of in-hospital mortality and the presence of congestive heart failure, dementia, and low albumin levels were associated with higher 30 days mortality.

Urban legend or real fact: Coronary artery size varies with demographics.

OBJECTIVE: This study aimed to determine the relationship between the diameter of coronary artery stents and age, gender, diabetes mellitus (DM), left ventricular ejection fraction (LVEF), renal dysfunction, and the clinical presentation of myocardial ischemia in the cohort of patients with implanted stents in coronary arteries with severe stenotic lesions. METHODS: This study included 2256 patients (mean age, 59.3±10.9 years; men, 62%) who underwent percutaneous coronary intervention (PCI). The clinical status of the patients at presentation was subcategorized as follows: ST-segment elevation myocardial infarction, non-ST segment elevation myocardial infarction, unstable angina pectoris, and stable angina pectoris. The diameters, without any type or brand differentiation, were divided into two groups as follows: Group I, which included 2.5- and 2.75-mm-diameter stents, and Group II, which included ≥3-mm-diameter stents. RESULTS: The type of procedure, including primary PCI, early invasive strategy, and elective stenting, was not found to be a significant factor affecting the diameter of coronary artery stents. Univariate and multivariate analyses revealed a relationship between the diameter of coronary artery stents and age, gender, DM, and LVEF. CONCLUSION: This study demonstrated that the diameter of coronary artery stents was independently associated with gender, age, a history of DM, and moderate-to-severe systolic left ventricular dysfunction.

Neurologic outcome in patients with cardiac arrest complicating ST elevation myocardial infarction treated by mild therapeutic hypothermia: The experience of a tertiary institution.

OBJECTIVE: Therapeutic hypothermia improves neurologic prognosis after cardiac arrest. The aim of this study was to report clinical experience with intravascular method of cooling in patients with cardiac arrest resulting from ST-segment elevation myocardial infarction (STEMI). METHODS: Thirteen patients (11 male, 2 famele; mean age was 39.6±9.4 years) who had undergone mild therapeutic hypothermia (MTH) by intravascular cooling after cardiac arrest due to STEMI were included. Clinical, demographic, and procedural data were analyzed. Neurologic outcome was assessed by Cerebral Performance Category (CPC) score. RESULTS: Anterior STEMI was observed in 9 patients. One patient died of cardiogenic shock complicating STEMI. Mean cardiopulmonary resuscitation (CPR) duration and door-to-invasive cooling were 32.9±20.1 and 286.1±182.3 minutes, respectively. Precooling Glasgow Coma Scale score was 3 in 9 subjects. Twelve patients were discharged, 11 with CPC scores of 1 at 1-year follow-up. No major complication related to procedure was observed. CONCLUSION: In comatose survivors of STEMI, therapeutic hypothermia by intravascular method is a feasible and safe treatment modality.

A case of Mobitz type II atrioventricular block due to Nerium oleander poisoning successfully managed with digoxin-specific Fab antibody fragments.

Nerium oleander is a popular ornamental plant grown in many tropical and subtropical countries and in the Mediterranean region. It is dangerous because it has been shown to contain several types of cardiac glycosides, and hence can cause cardiac arrhythmias resembling digoxin in their toxicologic manifestations. We report a patient presenting to our hospital with Mobitz type II atrioventricular block after drinking herbal tea prepared from oleander leaves. Three hours after admission, a 200-mg empiric dose of digoxin-specific Fab antibody fragments was administered intravenously over 30 minutes. A 12-lead electrocardiogram (ECG) revealed sinus rhythm at the end of infusion. After 72 hours, the patient was discharged without any symptoms.

Inappropriate use of digoxin in patients presenting with digoxin toxicity.

BACKGROUND: Digoxin remains widely used today despite its narrow therapeutic index and toxicity. The objective of this study was to investigate the percentage of inappropriate use of digoxin and long-term outcomes of elderly patients hospitalized for digoxin toxicity. METHODS: The study included 99 consecutive patients hospitalized for digoxin toxicity. The other study criteria for the inappropriate use of digoxin was regarded if participants having depressed left ventricular systolic function (ejection fraction < 45%) who were not on optimal medical therapy including beta-blocker and angiotensin-converting-enzyme inhibitor therapy or if participants having permanent AF who were not on optimal beta-blocker therapy. RESULTS: Appropriate digoxin usage was confirmed in 33 of patients in spite of its narrow therapeutic index. A total of 16 of 99 patients died, with a mean follow-up time of 22.1 ± 10.3 months. CONCLUSIONS: Contrary to popular belief, the rate of inappropriate digoxin usage remains high. On account of its narrow therapeutic index and toxicity, digoxin should be used more carefully according to the current evidence and guidelines.

Association between Glycosylated Haemoglobin Level and Contrast-Induced Acute Kidney Injury in Patients with Type 2 Diabetes Mellitus.

BACKGROUND: There are several reports suggesting that admission hyperglycaemia increases the risk of contrast-induced acute kidney injury (CI-AKI). However, it is not clear whether there has been an association between long-standing poor glycaemic control and the incidence of CI-AKI. The purpose of this study was to examine the impact of poor glycaemic control or elevated glycosylated haemoglobin (HbA1c) on the incidence of CI-AKI in patients with type 2 diabetes mellitus (T2DM). METHODS: The present study prospectively enrolled 133 patients with T2DM undergoing elective coronary angiography (CAG) and/or intervention. All patients had an estimated glomerular filtration rate (eGFR) of ≥60 ml/min/1.73 m(2). Patients were divided into two groups: those with an optimal HbA1c (<7%) and those with an elevated HbA1c (≥7%). All had similar baseline characteristics and were hydrated appropriately. The outcome was assessed by the incidence of CI-AKI. RESULTS: CI-AKI occurred in 2 of 41 patients (4.9%) with optimal HbA1c levels and 5 of 92 patients (5.4%) with elevated HbA1c levels (p = 0.89). The cutoff point of HbA1c was set at 6.5%, but no statistically significant difference between the two groups was observed [1 of 24 patients (4.1%) vs. 6 of 109 patients (5.5%), p = 0.79]. However, despite a high variability in the incidence of CI-AKI, there was no statistically significant difference between the two groups when varying CI-AKI definitions were considered. CONCLUSION: An elevated HbA1c level is not associated with a higher incidence of CI-AKI compared to optimal HbA1c levels in patients with T2DM (patients with an eGFR of ≥60 ml/min/1.73 m(2)) undergoing CAG and/or intervention.

The effect of rosuvastatin and atorvastatin on erectile dysfunction in hypercholesterolaemic patients.

BACKGROUND AND AIM: The aim of this study was to evaluate the effect of atorvastatin and rosuvastatin on erectile dysfunction in hypercholesterolaemic patients. METHODS: Ninety consecutive male hypercholesterolaemic patients (mean age 50.4 ± 7.9 years) who were otherwise healthy were included into the study prospectively. None of the patients had any cardiovascular risk factors except hypercholesterolaemia.The patients were divided into two groups. One group received atorvastatin while the other group was given rosuvastatin. All patients were followed for six months and International Index of Erectile Function-5 (IIEF-5) score and blood samples were re-evaluated. RESULTS: Patients were in similar ages in both groups. There were also no statistical differences in terms of blood glucose levels, total cholesterol, low density lipoprotein, high density lipoprotein, triglyceride and mean IIEF score in both groups at the beginning. After six months, no IIEF score changes were observed in the rosuvastatin group after the medication. However, the IIEF score was significantly lower in the atorvastatin group (p = 0.019). CONCLUSIONS: Rosuvastatin showed no effect on erectile dysfunction, while we observed increased erectile dysfunction with atorvastatin. Our study reveals that different statin types may have different effects on erectile dysfunction.

Anaphylactic shock associated with intravenous amiodarone.

A 64-year-old woman was admitted to our emergency department with shortness of breath and palpitation which started 2 h before her admission. She had a history of rheumatic mitral valve disease and was on drug treatment with warfarin and metoprolol. The patient was orthopneic, blood pressure was 108/68 mmHg with an irregular pulse with a heart rate of 158 beats per minute, and respiratory rate was 23 times per minute. Her electrocardiogram was consistent with atrial fibrillation with rapid ventricular response. For pharmacological cardioversion the patient was given amiodarone intravenous loading dose of 300 mg in 30 min. After 10 min of infusion the patient complained of pruritus and skin rash consistent with urticaria. At the same time the patient had dyspnea and bronchoconstriction was noted on both lung fields. The blood pressure was measured as 64/40 mmHg. The patient was taken to intensive care unit and supportive treatment for anaphylactic shock was given. Amiodarone is a class III antiarrhythmic agent frequently used in the management of atrial fibrillation. This potentially fatal complication of amiodarone should be kept in mind by clinicians and before administration patients should be questioned about previous allergic reactions including previous iodine or iodinated contrast media. Alternative agents should be considered in these conditions. .

Successful thrombolytic treatment of a bio-prosthetic mitral valve thrombosis in a pregnant woman.

Even though it is a rare complication, the pro-coagulant condition of pregnancy may predispose to thrombosis of a bio-prosthetic mitral valve (BPMV). We report the successful reduced-dose, slow infusion of tissue plasminogen activator (t-PA) to a BPMV thrombosis in a pregnant woman. When the patient was seen in the emergency clinic she was dyspnoeic and tachycardic and evaluated as NYHA class III-IV. On transthoracic echocardiography (TTE) the BPMV leaflet movement was restricted and a high transmitral valve gradient was measured.Transoesophageal echocardiography showed thrombosis of the BPMV. After slow infusion of t-PA with heparin, on TTE the gradient was decreased with free movement of the BPMV leaflet and with fast clinical improvement.

Impact of clopidogrel resistance on ST-segment resolution and no-reflow in acute myocardial infarction with ST-elevation patients treated with a primary percutaneous coronary intervention.

INTRODUCTION: A rapid restoration of epicardial coronary flow in acute myocardial infarction is crucial for saving jeopardized myocardium. The no-reflow phenomenon is one of the major problems in a primary percutaneous coronary intervention (PCI) and may be defined as an outcome of different pathological pathways. Our aim was to evaluate clopidogrel resistance in patients who underwent primary PCI and the relationship with the no-reflow phenomenon. MATERIALS AND METHODS: A total of 127 patients (mean age 54.0 ± 11.4 years, 83.7% men) were assessed for this purpose. No-reflow was defined as less than 50% ST-segment resolution on ECG. RESULT: No-reflow was significantly frequent in patients with clopidogrel resistance (25.3 vs. 57.1%, P=0.006). Univariate analysis and multivariate analysis showed that clopidogrel resistance and anterior myocardial infarction were only independent predictors of no-reflow phenomenon in patients treated with a primary PCI during acute myocardial infarction. CONCLUSION: Our study showed that clopidogrel resistance may be one of the responsible mechanisms for the no-reflow phenomenon. Assessment of simple ECG after a primary PCI may help clinicians to determine patients with a poor prognosis.

Long-term effect of bosentan therapy on cardiac function and symptomatic benefits in adult patients with Eisenmenger syndrome.

BACKGROUND: Bosentan improves symptoms in patients with Eisenmenger syndrome (ES). This study evaluated the effect of long-term bosentan therapy on cardiac function and its relation to symptomatic benefits in ES patients. METHODS AND RESULTS: Twenty-three consecutive adult ES patients (15 with ventricular septal defect, 6 with atrial septal defect, and 2 with patent ductus arteriosus) underwent standard and tissue Doppler echocardiography before and 24 ± 9 months after bosentan therapy. Echocardiographic measurements included pulmonary arterial systolic pressure (PASP), myocardial performance index (MPI), tricuspid and lateral mitral annular pulsed-wave tissue Doppler systolic (Sa) and early diastolic (Ea) long-axis motions. Patients' World Health Organization (WHO) functional class, 6-minute walk distance (6MWD), and systemic arterial oxygen saturations (SaO(2)) were also recorded. The PASP, WHO functional class, 6MWD, and SaO(2) all improved (118 ± 22 to 111 ± 19 mm Hg, 3.2 ± 0.4 to 2.4 ± 0.5, 286 ± 129 m to 395 ± 120 m, and 84.6 ± 6.5% to 88.8 ± 3.9%, respectively; all P < .01) after therapy. There was also significant improvement in right ventricular (RV) MPI (by 23.9%: 0.46 ± 0.15 to 0.35 ± 0.09) and biventricular long-axis function (tricuspid Sa and Ea: 6.7 ± 1.5 to 8.8 ± 1.7 cm/s and 5.7 ± 1.3 to 7.0 ± 1.2 cm/s, respectively; lateral Sa and Ea: 6.8 ± 1.3 to 8.4 ± 1.5 cm/s and 7.6 ± 2.0 to 8.5 ± 2.1 cm/s, respectively; all P < .05). Posttherapy RV MPI was moderately correlated with PASP and 6MWD. CONCLUSIONS: Sustained improvement of pulmonary arterial hypertension and RV function in ES patients was evident 2 years after bosentan therapy, and this may provide insights on the symptomatic benefits gained in these patients.

[Primary coronary intervention for acute ST-elevation myocardial infarction in a patient with immune thrombocytopenic purpura]. / Immün trombositopenik purpurali bir hastada akut ST yükselmeli miyokart enfarktüsü için primer koroner girisim uygulamasi

The ideal treatment for acute myocardial infarction in patients with idiopathic thrombocytopenic purpura (ITP) is not well-known. A 42-year-old male patient with a previous diagnosis of chronic and refractory ITP was admitted with chest pain of four-hour onset. Findings of electrocardiography was consistent with acute anteroseptal myocardial infarction. He had no risk factors for coronary heart disease and was not receiving treatment for ITP, and his platelet count varied between 11,000 and 40,000/µl before presentation, without any event of bleeding. Transthoracic echocardiography showed hypokinesia of the anterior, middle, and apical segments. Cardiac enzyme levels were elevated and platelet count was 41,000/µl. Coronary angiography revealed total occlusion of the left anterior descending artery. Primary percutaneous coronary intervention (PCI) was performed, which included predilation and stenting of the lesion. There were no bleeding or ischemic complications during or after PCI and the patient was discharged on the fifth day without any symptoms. He was instructed to take 75 mg clopidogrel daily for two weeks. He was symptom-free at a control visit after this period, with normal left ventricular wall motion on echocardiography.

An unusual microorganism, Aerococcus viridans, causing endocarditis and aortic valvular obstruction due to a huge vegetation.

Aerococcus viridans is not a common pathogen, and endocarditis due to A. viridans is very rare. A 44-year-old woman with persistent atrial fibrillation and rheumatic valvular heart disease was admitted with fever, sweating, weakness, and progressive shortness of breath. Transthoracic echocardiography (TTE) demonstrated a 8x9-mm vegetation attached to the right coronary cusp of the aortic valve, causing aortic obstruction. Blood cultures yielded A. viridans susceptible to penicillin. Despite optimal antibiotherapy, subsequent TTE controls revealed enlargement of the vegetation, reaching a size of 21x10 mm, and an increasing gradient across the aortic valve. The patient underwent successful aortic and mitral valve replacement and was stable in the postoperative period without any problem. This represents the first reported case of A. viridans endocarditis in which the size and location of vegetation caused obstruction to blood flow, indicating surgery.

Coexistent Brugada syndrome and Wolff-Parkinson-White syndrome: what is the first clinical presentation?

The coexistence of Brugada syndrome and Wolff-Parkinson-White (WPW) syndrome is a very rare phenomenon. We describe a 31-year-old patient without any previous cardiac disorder admitted to our hospital due to palpitations and concomitantly diagnosed as WPW syndrome and treated with radiofrequency catheter ablation. He was later diagnosed with Brugada syndrome and followed-up 2 years without any symptoms. We discuss other previously reported cases in literature, in which these two conditions exist simultaneously.

Isolated left ventricular noncompaction: a small, noncompacted segment may cause serious complications.

INTRODUCTION: Isolated left ventricular noncompaction is a rare form of cardiomyopathy. Heart failure with deteriorated systolic function is the hallmark of this cardiomyopathy. Albeit it may cause ventricular tachycardia (VT) and systemic embolism, it is a rarity to see these complications in a patient with noncompaction and normal systolic functions. CASE REPORT: A 78-year old female patient with a history of cerebrovascular accident admitted to our hospital with palpitation and subsequently developed cardiopulmonary arrest. Her ECG showed ventricular tachycardia degenerated into fibrillation. Echocardiography and cardiac magnetic resonance (CMR) revealed a small noncompacted segment in left ventricular apex. Ventricular tachycardia was induced in electrophysiologic study and an implantable cardioverter-defibrillator was implanted. DISCUSSION: Patients with isolated left ventricular noncompaction usually present with heart failure symptoms and subsequently diagnosed with echocardiography. Rarely, it may cause ventricular tachycardia and systemic embolism in a patient with normal systolic functions and a small noncompacted segment. Noncompaction should be carefully sought in unexplained ventricular tachycardia and cerebrovascular accidents, even if heart failure is not present.

Acute type A aortic dissection and left main coronary artery obstruction detected by transesophageal echocardiography.

A 63-year-old man was admitted with severe chest pain. The electrocardiogram demonstrated ST-segment depression in the anterior and lateral leads suggesting acute anterior myocardial ischemia. Contrast-enhanced thoracic computed tomography performed due to severe back pain showed acute dissection of the descending aorta. Coronary angiography showed normal coronary arteries. Transesophageal echocardiography revealed a Stanford type A aortic dissection involving the left main coronary ostium and causing left main coronary occlusion. The dissected flap caused partial obstruction of the coronary ostium and occasional separation of the lumen, resulting in nonsustained ventricular tachycardia. At emergency operation, the entry of the dissection was seen in the ascending aorta and the dissection extended throughout almost the entire sinus of Valsalva and the left main coronary trunk. The aortic flap was seen in the coronary ostium. Both the right and left coronary arteries were prepared widely and sutured directly to a composite graft. The ascending aorta was replaced with a composite graft through a Bentall procedure. Descending aortic repair was planned for a subsequent operation. The patient was hemodynamically stable for three weeks, but then developed respiratory insufficiency due to severe nosocomial pneumonia and died one month after the operation.