Stress Hyperglycemia Ratio Is Associated With High Thrombus Burden in Patients With Acute Coronary Syndrome.

The blood glucose level at admission indicates (with some limitations) poor prognosis and thrombus burden in patients with the acute coronary syndrome (ACS). Our study aimed to measure the predictive value of the stress hyperglycemia ratio (SHR), an indicator of stress hyperglycemia, showing increased thrombus burden in patients with ACS. Patients (n = 1222) with ACS were enrolled in this cross-sectional study. Coronary thrombus burden was classified as high and low. SHR was calculated by dividing the admission serum glucose by the estimated average glucose derived from HbA1c. Low thrombus burden was detected in 771 patients, while high thrombus burden (HTB) was detected in 451 patients. SHR was found to be significantly higher in patients with HTB (1.1 ± .3 vs 1.06 ± .4; P = .002). SHR was determined as a predictor of HTB (odds ratio (OR) 1.547 95% CI (1.139-2.100), P < .001) as a result of univariate analysis. According to multivariate analysis, SHR was determined as an independent risk factor for HTB (OR 1.328 CI (1.082-1.752), P = .001). We found that SHR predicted thrombus burden with higher sensitivity than admission glucose level in patients with ACS.

Frontal QRS - T angle is associated with severity and prognosis of acute pulmonary embolism.

INTRODUCTION: The pathological effects of acute pulmonary embolism (APE) on the right ventricle are one of the most important determinants of mortality in patients with APE. Frontal QRS-T angle (fQRSTa) predicts ventricular pathology and poor prognosis in many different cardiovascular diseases. In this study, we investigated whether there is a significant relationship between fQRSTa and APE severity. MATERIAL AND METHODS: A total of 309 patients were included in this retrospective study. The severity of APE was classified as massive (high risk), submassive (intermediate risk), or nonmassive (low risk). fQRSTa calculated from standard ECGs. RESULTS: fQRSTa was significantly higher in massive APE patients (p < 0.001). fQRSTa was also found to be significantly higher in the in-hospital mortality group (p < 0.001). fQRSTa was an independent risk factor for the development of massive APE (odds ratio:1.033; 95% CI: 1.012-1.052; p < 0.001). CONCLUSION: Our study showed that increased fQRSTa predicts high-risk APE patients and mortality in APE patients.

Successful closure of the ventricular septal defect;A rare complication after transcatheter aortic valve replacement.

In this report, we present a patient with ventricular septal defect (VSD) that was detected at follow-up one month after transcatheter aortic valve implantation (TAVI) and successfully closed percutaneously. Before the procedure, a 29 mm Portico self-expanding aortic valve prosthesis was placed in the heavy calcific aortic valve position, and then the balloon was dilated due to aortic insufficiency and excellent results were obtained. One month after TAVI, the patient complained of shortness of breath at rest, and on physical examination a pansystolic murmur was detected. Transthoracic echocardiography (TTE) revealed a well-functioning prosthetic aortic valve; however, a VSD was detected causing left-to-right shunt in the interventricular septum. Later, we performed the interventional treatment of the defect using the Amplatzer muscular VSD occluder device with the transfemoral approach. Currently, five months after the combined procedure, the patient showed a significant improvement in symptoms and no significant shunt was observed.

Tp-e/QTc ratio, SYNTAX, and GRACE score in patients who underwent coronary angiography owing to acute coronary syndrome.

OBJECTIVE: Ventricular arrhythmias following acute coronary syndrome (ACS) range from benign to life-threatening fatal arrhythmias. Tpeak-end (Tp-e) interval has been shown to be an important parameter in the assessment of repolarization dispersion. We aimed to evaluate the relationship between SYNTAX and Global Registry of Acute Coronary Events (GRACE) risk score calculated on admission and Tp-e interval and Tp-e/QTc ratio. METHODS: A total of 421 patients were included in the study. The patients were divided into 2 groups as low SYNTAX score (≤22) and moderate and high risk SYNTAX score (>22). According to the GRACE risk score, the patients were divided into 2 groups; high-risk patients ≥140 and <140 low-risk patients. RESULTS: In the group with SYNTAX score >22, the Tp-e interval (p<0.001) and Tp-e/QTc ratio (p<0.001) was found to be significantly higher than in the group with a SYNTAX score ≤22. Tp-e interval (p<0.001) and Tp-e/QTc ratio (p=0.002) was higher in patients with GRACE risk score ≥140 compared with patients with a GRACE risk score <140. The correlation between Tp-e interval and Tp-e/QTc ratio and SYNTAX score (r=0.489; p<0.001) and GRACE risk score (r=0.274; p<0.001) were found to be significant. A significant and independent correlation was found between the SYNTAX score and Tp-e/QTc ratio (ß=0.385; p<0.001). CONCLUSION: Tp-e interval and Tp-e/QT ratio increased in patients with severe coronary artery disease assessed with SYNTAX score. Tp-e interval and Tp-e/QT ratio increased in patients with a high GRACE risk score.

Relationship between serum bilirubin levels and presence of fragmented QRS in patients with acute coronary syndrome.

Aim: To assess the relationship between serum bilirubin levels and fragmented QRS (fQRS), and their association with adverse events in patients with acute coronary syndrome. Methods: This study included a total of 736 patients. Laboratory results such as bilirubin levels, renal and liver function tests were obtained from the first available blood sample. Results: Left ventricular ejection fraction, end-diastolic diameter and total bilirubin level were significantly lower in fQRS (+) group than in the control group (45.0 [40.0-55.0] vs 50.0 [45.0-60.0]%; p < 0.001; 4.7 [4.6-5.1] vs 4.7 [4.5-4.9] cm; p < 0.001; 0.66 [0.49-5.1] vs 0.72 [0.53-0.97] md/dl; p = 0.017); respectively. Occurrence of adverse events was significantly higher in fQRS (+) group (32.5 vs 20.5 %; p = 0.013) during mean 1-year follow-up period. Conclusion: Total bilirubin level is an independent predictor of fQRS formation, which is associated with the presence of adverse events in patients with acute coronary syndrome.

Comparison of atrial fibrillation predictors in patients with acute coronary syndrome using ticagrelor or clopidogrel

Background/aim: Ticagrelor is a drug widely used in patients with acute coronary syndromes (ACS) that specifically increases the plasma level of adenosine, which is likely to cause atrial fibrillation (AF). Therefore, in this study we aimed to investigate the electrocardiographic and echocardiographic predictors of AF development after P2Y12 receptor antagonists in ACS patients. Materials and methods: This cross-sectional study included 831 patients with ACS (486 [58.5%] with ST elevated myocardial infarction [STEMI] and 345 [41.5%] with non-ST elevated myocardial infarction [NSTEMI]). Patients were divided into ticagrelor (n = 410) and clopidogrel (n = 421) groups. P wave properties including P wave dispersion and atrial electromechanical conduction properties were measured as AF predictors with surface ECG and tissue Doppler imaging. Results: Baseline characteristics such as age, sex, heart rate, blood pressure, and laboratory parameters were almost the same in the ticagrelor and clopidogrel groups. The statistical analysis showed no significant difference in P wave dispersion (PWD) between ticagrelor and clopidogrel groups (40.98 ± 12 ms versus 40.06 ± 12 ms, P = 0.304). Subgroups analysis according to ACS types also showed no significant difference in PWD (NSTEMI: 41.16 ± 13.8 ms versus 40.76 ± 13.55 ms, P = 0.799; STEMI: 40.9 ± 12.62 ms versus 39.19 ± 11.18 ms, P = 0.132). In addition, we did not find significant difference in atrial electromechanical delay (EMD) with tissue Doppler imaging (interatrial EMD 24.11 ± 3.06 ms versus 24.46 ± 3.23 ms, P = 0.279). Conclusion: In conclusion, we did not find any difference in detailed electrocardiographic and echocardiographic parameters as AF predictors between ticagrelor and clopidogrel groups in patients with ACS

Pulmonary Arterial Hemodynamic Assessment by a Novel Index in Systemic Sclerosis Patients: Pulmonary Pulse Transit Time.

OBJECTIVES: Systemic sclerosis (SSc) is a chronic, inflammatory, and autoimmune connective tissue disease that is associated with vascular lesions, and fibrosis of the skin and visceral organs. Cardiac complications may occur as a secondary effect of SSc as a result of pulmonary arterial hypertension and interstitial lung disease. The objective of this study was to assess whether the pulmonary pulse transit time (pPTT) could serve as a diagnostic marker for pulmonary arterial alterations in patients with SSc, prior to development of pulmonary hypertension. METHODS: Twenty-five SSc patients as a study group and 25 age- and sex-matched healthy volunteers for the control group were recruited to the study. Right ventricle function parameters, such as tricuspid annular plane systolic excursion (TAPSE), estimated pulmonary artery systolic pressure (ePASP), right ventricular dimensions, right ventricle fractional area changes, and myocardial perfusion index (MPI) were measured and calculated. Pulmonary pulse transit time was defined as the time interval between the R-wave peak in the ECG and the corresponding peak late systolic pulmonary vein flow velocity. RESULTS: Right ventricle myocardial performance index (RVMPI) and eSPAP were significantly higher in the SSc group than the controls (p = 0.032, p = 0.012, respectively). Pulmonary pulse transit time and TAPSE was shorter in the patients with SSc (p = 0.006, p = 0.015, respectively). In correlation analysis, pPTT was inversely correlated with RVMPI (r = - 0.435, p = 0.003), eSPAP (r = - 0.434, p = 0.003), and disease duration (r = - 0.595, p = 0.003). Conversely, it positively correlated with TAPSE (r = 0.345, p = 0.022). CONCLUSION: pPTT was found to be shorter in SSc patients. pPTT might serve as a surrogate marker of pulmonary hemodynamics in patients with SSc, even prior to the development of pulmonary hypertension.

Analysis of MMP-7 and TIMP-2 gene polymorphisms in coronary artery disease and myocardial infarction: A Turkish case-control study.

Matrix metalloproteinase (MMP) and tissue inhibitors of metalloproteinase (TIMP) have a significant role in tissue remodeling related to cardiac function. In earlier studies, MMP-7 A-181G (rs11568818), C-153T (rs11568819), C-115T (rs17886546), and TIMP-2 G-418C (rs8179090) polymorphisms have been studied in various diseases. However, association between coronary artery disease (CAD) and these polymorphisms has been poorly studied. The goal of this study is to investigate the association of CAD and myocardial infarction (MI) with MMP-7 or TIMP-2 polymorphisms. This study included 122 CAD patients and 132 control individuals. DNA was extracted from whole blood. Polymerase chain reaction-restriction fragment length polymorphism and automated direct sequencing method were used for genotyping of these polymorphisms. No significant differences were found between MMP-7 A-181G, C-115T, and TIMP-2 G-418C polymorphism and CAD or MI in a Turkish population. Despite the fact that the genotypes of MMP-7 C-153T polymorphism had no significant differences among MI and control groups, allele frequencies of C-153T polymorphism were significantly different between the two groups. Our study is the first report to clarify the appreciable relationship between MMP-7 C-153T polymorphism and MI development in CAD patients. However, these findings also need to be confirmed in other populations so we can improve our knowledge about the genetic factors affecting the development of CAD.

What Lies behind the Ischemic Stroke: Aortic Dissection?

Introduction. Some cases with aortic dissection (AD) could present with various complaints other than pain, especially neurological and cardiovascular manifestations. AD involving the carotid arteries could be associated with many clinical presentations, ranging from stroke to nonspecific headache. Case Report. A 71-year-old woman was admitted to emergency department with vertigo which started within the previous one hour and progressed with deterioration of consciousness following speech disorder. On arrival, she was disoriented and uncooperative. Diffusion magnetic resonance imaging (MRI) of brain was consistent with acute ischemia in the cerebral hemisphere. Fibrinolytic treatment has been planned since symptoms started within two hours. Echocardiography has shown the dilatation of ascending aorta with a suspicion of flap. Computed tomography (CT) angiography has been applied and intimal flap has been detected which was consistent with aortic dissection, intramural hematoma of which was reaching from aortic arch to bilateral common carotid artery. Thereafter, treatment strategy has completely changed and surgical invention has been done. Conclusion. In patients who are admitted to the emergency department with the loss of consciousness and stroke, inadequacy of anamnesis and carotid artery involvement of aortic dissection should be kept in mind.

Relation of kynurenine/tryptophan with immune and inflammatory markers in coronary artery disease.

BACKGROUND: Inflammation and immune activation have a crucial role in the pathogenesis of cardiovascular diseases. Indolamine 2,3-dioxygenase, a tryptophan catabolising enzyme, is up-regulated with various inflammatory stimuli. The aim of this study was to evaluate the relationship of tryptophan degradation with immune and inflammatory markers in coronary artery disease. METHODS: 57 subjects undergoing coronary angiography were recruited. 18 subjects with normal coronary arteries according to Gensini scoring were selected as a control group and the rest of subjects were included in patient group. Serum tryptophan and kynurenine levels were determined with HPLC-UV method, and kynurenine/tryptophan ratio was evaluated as IDO activity. Serum neopterin and myeloperoxidase activity were measured by ELISA method. RESULTS: While the kynurenine/tryptophan ratio and neopterin levels were similar in both groups, the patient group had higher myeloperoxidase and hs-CRP levels than controls (p = 0.02, p = 0.002, respectively). The kynurenine/tryptophan ratio was correlated with neopterin in both groups (r = 0.389, p = 0.025; r = 0.683, p = 0.002, respectively) and with hs-CRP in patients (r = 0.637, p = 0.001). Also, neopterin levels were correlated with hs-CRP in patients (r = 0.755, p = 0.0001). CONCLUSIONS: Our results are in line with a role of inflammation in coronary artery disease. The study provides evidence that IDO activity is related with immune and inflammatory states. Also, the study was performed in a limited hospital-based population. Further studies are warranted in the larger groups.

Conservative treatment of femoral neuropathy following retroperitoneal hemorrhage: a case report and review of literature.

Anticoagulant drugs are used to reduce the incidence of thromboembolic events in patients at risk. However, minor and major bleeding complications may occur during anticoagulation therapy. Femoral neuropathy secondary to retroperitoneal hematoma is a well known complication of anticoagulant drugs. However, treatment of these patients is still controversial, both conservative and surgical treatments have been advocated. Herein, we report a male patient receiving warfarin for 7 years who developed femoral neuropathy due to retroperitoneal hematoma and was successfully treated with conservative methods. We suggest that conservative treatment and appropriate rehabilitation program should be given to the patients who do not demonstrate any signs of a continued bleeding and any progressive neurological deficits.

Markers of endothelial dysfunction and evaluation of vascular reactivity tests in Behçet disease.

We assessed endothelial dysfunction (ED) in patients with Behcet disease (BD; n=40) and healthy controls (n=20). Serum lipid, homocysteine, asymmetric dimethylarginine (ADMA) and high-sensitivity C-reactive protein (hsCRP) levels, erythrocyte sedimentation rates (ESRs), and ultrasonographic flow-mediated dilatation (FMD) were measured. Mean hsCRP, ESR, homocysteine, and ADMA were significantly higher in the BD group (P<.001 for all). Patients with active BD had higher serum levels of hsCRP, homocysteine, and ESR compared with those in remission (P<.001, P<.001, and P=.005, respectively). Flow-mediated dilatation was significantly lower in patients with BD than in controls (P=.001). Flow-mediated dilatation correlated negatively with BD duration and serum ADMA levels (P<.001, r=-.745 and P<.001, r=-.682); a positive correlation was seen between serum ADMA levels and BD duration (P<.001, r=.552). Only stepwise multivariate regression analysis revealed BD duration to have a significant effect on FMD. Flow-mediated dilatation, in conjunction with markers of inflammation, may evaluate ED in patients with BD.

Bilirubin levels and the burden of coronary atherosclerosis in patients with STEMI.

We investigated whether serum bilirubin level (a marker of heme oxygenase activity) is a predictor of high levels of SYNTAX score (SXscore) in patients with acute myocardial infarction. Patients (n = 281; male 77%; mean age 60 ± 12) who were admitted with ST-elevation myocardial infarctions (STEMIs) were enrolled. Patients were divided into 2 groups. Group 1 was defined as SXscore <22 and group 2 was defined as SXscore ≥22. Total bilirubin levels were significantly higher in the high-SXscore group than in the low-SXscore group (0.86 ± 0.42 vs 1.02 ± 0.51, P = .005). A significant correlation was detected between total bilirubin and SXscore (r = .42; P = .001). At multivariate analysis, total bilirubin (odds ratio: 1.86, 95% confidence interval 1.04-3.35; P = .038) was an independent risk factor for high SXscore in patients with STEMI. In conclusion, serum bilirubin level is independently associated with SXscore in patients with STEMI.

Atrial electromechanical coupling interval and P-wave dispersion in healthy elderly.

BACKGROUND AND AIMS: The aim of our study was to investigate the potential effect of natural aging on atrial fibrillation (AF) by means of electrocardiographic P-wave analysis and measurement of the transthoracic echocardiographic electromechanical coupling interval (EMC). METHODS: The study comprised 25 healthy individuals aged ≥65 years (group 1) and 25 control subjects <65 years (group 2). The difference between maximum (Pmax) and minimum (Pmin) P-wave durations on 12-lead electrocardiography were defined as P-wave dispersion (PD). Intra- and inter-atrial EMC were measured by tissue Doppler imaging. RESULTS: Pmax (107.2 ± 3.58 msec vs 100.0 ± 3.56 msec, p<0.001) and PD (43.6 ± 4.98 msec vs 36.5 ± 3.56 msec, p<0.001) were significantly higher in group 1 than in group 2. Left atrial EMC [24.6 (15.20) vs 13.3 (4.50), p<0.001] and inter-atrial EMC [43.2 (16.05) vs 33.3 (4.75), p<0.001] were significantly delayed in group 1 compared with group 2. There was a significant correlation between left atrial diameter, PD, Pmax, left atrial EMC, and inter-atrial EMC. CONCLUSION: Aging is correlated with increased left atrial size and impaired diastolic relaxation, which may contribute to a greater risk of AF in terms of prolonged PD and atrial EMC.

Preoperative exercise heart rate recovery predicts intraoperative hypotension in patients undergoing noncardiac surgery.

STUDY OBJECTIVE: To assess the predictive role of heart rate (HR) recovery in the detection of intraoperative hypotension in patients undergoing noncardiac surgery. DESIGN: Prospective, observational study. SETTING: Department of cardiology and operating rooms of university hospitals. PATIENTS: 160 ASA physical status 1 and 2 patients scheduled for elective noncardiac surgery. MEASUREMENTS: All patients underwent exercise stress testing. Maximum HRs and metabolic equivalent levels were recorded. Heart rate recovery at the first, second, and third minutes were calculated by subtracting HRs one, two, and three minutes into the recovery period from the maximal HR at peak exercise. A decrease in mean arterial pressure (MAP) of greater than 30% was defined as intraoperative hypotension and recorded. Patients were classified to two groups according to whether they had intraoperative hypotension. MAIN RESULTS: Hypotensive episode was observed in 31 patients (19.7%) during the operation. The presence of diabetes mellitus was higher in patients with intraoperative hypotension (22.6% vs 7.1%, P = 0.019). Mean HR recovery at the first, second, and third minutes was significantly lower in the intraoperative hypotension group (P = 0.001, P = 0.004, and P = 0.031, respectively). Heart rate recovery at the first, second, and third minutes was a good predictor of intraoperative hypotension, but only HR recovery at the first minute (OR 0.82, 95% CI 0.73 to 0.92, P = 0.001) and HR recovery at the second minute (OR, 0.90; 95% CI, 0.82 to 0.98; P = 0.019) were independent predictors of intraoperative hypotension. A higher negative correlation was noted between the degree of MAP reduction and HR recovery at the first minute (r = -0.797, P = 0.001). CONCLUSIONS: Abnormal preoperative exercise HR recovery predicts intraoperative hypotension in patients undergoing noncardiac surgery. Given the importance of intraoperative hypotension, preoperative use of exercise testing might be considered.

Effect of overweight and obesity on the left ventricular systolic and diastolic functions in patients with acute myocardial infarction.

PURPOSE: The purpose of this study was to evaluate whether a association exits among overweight and obesity and left ventricular systolic and diastolic functions in patients admitted with first ST-elevation myocardial infarction (STEMI). METHODS: The present study was performed on 451 consecutive patients diagnosed with first STEMI (376 men, 75 women; mean age 56.1 ± 10.8 years). The patients were classified into three groups based on their body mass index (BMI) as normal weight (BMI < 25 kg/m2), overweight (BMI: 25-29.9 kg/m2) and obese (BMI > 30 kg/m2). Echocardiographic features were evaluated and compared among the three groups. RESULTS: Mitral annulus E velocities were higher in obese individuals than normal weight group (p < 0.01). In contrast, mitral A velocities were lower (p =0.03); consequently, E\A and E'\A' ratios were lower (both p = 0.01) in the obese group with respect to normal weight group. When the correction of entire variations existing among the groups were performed using multivariate linear regressions analyses, it turned out that BMI was independently associated with E/A (ß = -0.19, p = 0.044) and with E'/A' (ß = -0.016, p = 0.021). Ejection fraction, wall motion score index and myocardial S velocities were comparable among the study groups (p > 0.05). CONCLUSION: These results suggest that while obesity has no adverse effect on the left ventricular systolic function, it has unfavorable consequences on the left ventricular diastolic function in the patients with first STEMI. In contrast, no unfavorable effects of overweight on the left ventricular systolic and diastolic function were detected.

Effect of overnight nasal continuous positive airway pressure treatment on the endothelial function in patients with obstructive sleep apnea.

OBJECTIVE: In this prospective study, we aimed to investigate acute effect of nasal continuous positive airway pressure (CPAP) therapy on the endothelial function of patients with obstructive sleep apnea syndrome (OSA) by using brachial artery flow mediated dilatation (FMD) method. METHODS: Newly diagnosed thirty OSA patients with ages between 29 and 72 years were included in this study. FMD and high sensitivity C-reactive protein (hsCRP) values of patients obtained before and after CPAP dose titration test were compared with paired samples t test or Wilcoxon signed ranks test. RESULTS: With CPAP therapy apnea hypopnea indices were reduced (60.6±24.9/h vs. 9.6±7.9/h; p<0.001) and oxygen desaturation indices recovered (50±27/h vs. 6±7/h; p<0.001). Heart rates of patients decreased after CPAP therapy (80±10/min vs. 73±8/min; p=0.003). FMD values significantly increased after CPAP (8.55±5.82 percent vs. 12.08±7.17 percent; p=0.003). HsCRP values after CPAP were not different from baseline values. CONCLUSION: Acute improvement of the endothelial function with one night CPAP therapy suggests endothelial dysfunction in OSA patients to be result of acute pathophysiologic factors. In intermediate and severe OSA patients, CPAP therapy may be considered in acute treatment of diseases associated with endothelial dysfunction.

Atrial electromechanical coupling interval and P-wave dispersion in patients with white coat hypertension.

BACKGROUND: The aim of our study was to investigate the effect of white coat hypertension (WCH) to atrial conduction abnormalities by electrocardiographic P-wave analysis and echocardiographic electromechanical coupling (EMC) interval measurement. METHODS: The study consisted of sex-, age-, and body mass index-matched 24 patients with WCH, 24 patients with sustained hypertension (SH), and 24 subjects with normotension (NT). The difference between the maximum (Pmax) and minimum P-wave durations on 12-lead electrocardiography was defined as P-wave dispersion (PD). Intra- and inter-atrial EMC were measured by tissue Doppler imaging. RESULTS: Pmax and PD of subjects with WCH were significantly higher than those of normotensives and lower than those of patients with SH. Inter-atrial EMC and left atrial EMC values of WCH group were intermediate between NT and SH groups. There was a significant correlation between left atrial diameter, PD, Pmax, left ventricle mass index, left atrial EMC, and inter-atrial EMC. CONCLUSION: White coat hypertension is an intermediate group between SH and NT in terms of atrial electromechanical abnormalities which may be associated with the risk of atrial fibrillation.