A new inflammatory marker: elevated eosinophil-tolymphocyte ratio associated with presence and severity of isolated coronary artery ectasia.

OBJECTIVES: The pathophysiology of isolated coronary artery ectasia (CAE) involves atherosclerosis and inflammation. Eosinophils and lymphocytes have been found to play a significant role in inflammation, atherosclerosis and endothelial dysfunction. Many studies have explored the relationship between isolated CAE and systemic inflammation. However, there are no data regarding the relationship between eosinophil-to-lymphocyte ratio (ELR) and isolated CAE. Therefore, this study analysed the relationship between ELR and isolated CAE. METHODS: All patients who underwent coronary angiography between January 2009 and June 2018 were investigated retrospectively. Of 16 240 patients, 232 patients with isolated CAE (141 males) and 247 age- and gender-matched control subjects (130 males) with normal coronary angiography (NCA) were enrolled in this study. Baseline demographic and laboratory data were obtained from the hospital database. The severity of isolated CAE was determined according to the Markis classification, vessel count and diffuseness of ectasia. RESULTS: Patients with angiographic isolated CAE had significantly elevated white blood cell (WBC) and eosinophil counts and ELR values compared to patients with NCA [8.11 ± 1.75 vs 7.49 ± 1.80 × 109 cells/l, p < 0.0001; 0.22 (0.13-0.32) vs 0.19 (0.12-0.28) × 109 cells/l, p = 0.02; 0.11 (0.06-0.17) vs 0.08 (0.05-0.12), p < 0.0001. The ELR value for Markis I was significantly higher than for Markis IV (p = 0.04), and three-vessel isolated CAE was significantly higher than onevessel isolated CAE (p = 0.04). Additionally, the ELR value for diffuse ectasia (Markis class I, II and III) was significantly higher compared to focal (Markis class IV) ectasia (p = 0.02). In receiver operating characteristics (ROC) analyses, it was determined that an ELR value > 0.099, measured in isolated CAE patients at application, had a predictive specificity of 60.3% and a sensitivity of 56.5% (area under the curve: 0.604, 95% confidence interval: 0.553-0.655, p < 0.0001). CONCLUSIONS: Patients with isolated CAE had higher blood eosinophil counts and ELR. Furthermore, the ELR was significantly correlated with severity of isolated CAE. These findings demonstrate that ELR may have a significant role in the aetiopathogenesis of isolated CAE.

Spotlights on some electrocardiographic paradigms: How should we evaluate normal reference values of Tp-Te interval, Tp-Te dispersion and Tp-Te/QT ratio?

BACKGROUND: Experimental and clinical studies evaluating the Tp-Te interval and Tp-Te/QT ratio have reported conflicting data. The overlap between normal Tp-Te/QT ratios (0.17 ±0.02-0.27 ±0.06 ms) and pathological values (0.20 ±0.03-0.30 ±0.06 ms) measured in earlier studies has raised questions about this ECG measurement technique. OBJECTIVES: To analyze normal values of the Tp-Te interval, Tp-Te dispersion Tp-Te(d) and the Tp-Te/QT ratio based on electrocardiographic (ECG) assessment across sex and age groups in a healthy Turkish population. MATERIAL AND METHODS: A total of 1,485 healthy participants (723 men) were enrolled into the study. The age of the participants ranged 17-75 years and they did not have either any cardiovascular/systemic disorders or risk factors for atherosclerosis which were detected with physical examination and laboratory tests. The Tp-Te interval, Tp-Te(d) and Tp-Te/QT ratio were determined from V1-V6 derivations. RESULTS: For the entire study, the median Tp-Te interval was 66.0 (64.0-70.0) ms, the Tp-Te(d) was 15.0 (10.0-20.0) ms, and the Tp-Te/QT ratio was 0.18 (0.17-0.19). The Pearson's correlation test demonstrated that the Tp-Te/QT ratio significantly correlated with older age (r = 0.297; p < 0.0001), left ventricular (LV) end-diastolic diameter (LVEDD; r = 0.481; p < 0.0001), body mass index (BMI; r = 0.421; p < 0.0001), body surface area (BSA; r = 0.191; p < 0.0001), LV end-diastolic volume (LVEDV; r = 0.484; p < 0.0001), LVEDV index (r = 0.450; p < 0.0001), LV mass (r = 0.548; p < 0.0001), and LV mass index (r = 0.539; p < 0.0001). CONCLUSIONS: The reference values for Tp-Te interval, Tp-Te(d) and Tp-Te/QT ratio are associated with age, BMI, BSA, LVEDV, LVEDV index, LV mass, and LV mass index. These structural elements should be considered when using these ECG parameters for assessing repolarization inhomogeneity. These findings may guide further studies assessing healthy and diseased populations.

Is there a relationship between epicardial fat tissue thickness and Tp-Te/QT ratio in healthy individuals?

INTRODUCTION: Epicardial fat is a tissue that releases many proinflammatory and atherogenic mediators, with endocrine and paracrine effects on the heart. In this study, the implication of the EFT thickness (EFTt) on transmural dispersion of repolarisation (TDR) was analysed utilizing the T-wave peak to end interval (Tp-Te), the Tp-Te dispersion (Tp-Te (d)), and the Tp-Te/QT ratio. MATERIAL AND METHODS: One thousand seven hundred and thirteen subjects were enrolled in the research. The subjects were chosen to be healthy individuals, without any cardiovascular/systemic disorders or risk factors for atherosclerosis. Transthoracic echocardiography (TTE) was applied to all subjects, and EFTt was measured in both diastole and systole. The ECG measurements were taken from standard 12-lead surface ECG. RESULTS: Correlation analysis revealed that the EFTt is highly associated with the Tp-Te interval, Tp-Te/QT ratio, Tp-Te (d), increasing age, body mass index (BMI), body surface area (BSA), left ventricular (LV) mass, LV mass index, plasma glucose during fasting, triglycerides, and low-density lipoprotein cholesterol. CONCLUSIONS: The study results showed that increased EFTt was associated with increased TDR values of Tp-Te, Tp-Te (d), and Tp-Te/QT ratio, even in the absence of other factors that could increase TDR and EFTt. Therefore, it can be stated that increased EFTt may cause an increase the risk for ventricular arrhythmia.

Performance of HAS-BLED and CRUSADE risk scores for the prediction of haemorrhagic events in patients with stable coronary artery disease.

We aimed to compare the power of the HAS-BLED and CRUSADE risk scores in predicting in-hospital bleeding events in patients with stable coronary artery disease undergoing elective coronary angiography. A total of 405 consecutive patients were included in the study. The mean HAS-BLED score was significantly higher (p < 0.001) in the in-hospital bleeding group. In patients with a HAS-BLED score ≥ 3, the in-hospital bleeding rate was significantly higher than in those with a HAS-BLED score < 3 (p < 0.001). Receiver operating characteristic curve analysis revealed that the HAS-BLED score was superior in predicting in-hospital bleeding events compared to the CRUSADE score [area under the curve (AUC) = 0.684 vs 0.569, respectively, p = 0.002]. Also in the percutaneous coronary intervention subgroup, the HAS-BLED score was superior to the CRUSADE score (AUC = 0.722 vs 0.520, respectively, p = 0.002). We showed that the HAS-BLED and CRUDASE scores are helpful in stable patients undergoing elective coronary angiography. Our results suggest that as a practical, easy-to-implement and more predictive scoring system, the HAS-BLED score was more useful for predicting in-hospital bleeding in patients who did not present with acute coronary syndrome.

Is Fasting for Ramadan Safe in Patients with Mechanical Cardiac Valves?

BACKGROUND AND AIM OF THE STUDY: The study aim was to investigate the safety and effects of fasting during Ramadan on the International Normalized Ratio (INR) in patients with mechanical cardiac valves. METHODS: A total of 105 patients admitted to the authors' hospital between June and October 2015, who had history of prosthetic valve replacement, was investigated. The patients were allocated to two groups: those fasting during Ramadan (n = 42) and those not fasting (n = 63). All patients were examined by a cardiologist, and the clinical findings and complaints for the past three months were evaluated. The INR, complete blood count (CBC) and a basic biochemical panel were monitored for all patients. RESULTS: The mean corpuscular volume (MCV) of the fasting group was significantly higher than that of the non- fasting group (87.59 ± 6.39 (µm3) versus 84.28 ± 6.387 (µm3); p = 0.011). Other CBC parameters and basic biochemical values did not differ significantly different between groups. Neither were significant differences noted in INR values during Ramadan (fasting group 2.87 ± 0.97; non-fasting group 2.73 ± 0.78; p = 0.50) and at routine control one month later (fasting group 3.07 ± 1.55; non-fasting group 2.94 ± 1.03; p = 0.601). No significant differences related to increased rates of hospitalization, valvular dysfunction on echocardiography, thrombus, embolism, bleeding and clinical complaints were identified between the groups. CONCLUSIONS: Fasting during Ramadan had no adverse effects on the INR of patients, and appears to be safe for patients with mechanical prosthetic cardiac valves.

Focusing on a complete blood cell parameter: mean platelet volume levels may be a predictor of coronary slow flow.

BACKGROUND: The relationship between increased mean platelet volume (MPV) and atherosclerosis is well known. In the present study, MPV in patients with coronary slow flow (CSF) and in cases with normal coronary anatomy (NCA) was investigated and compared with the aim of identifying the relationship between CSF and MPV. PATIENTS AND METHODS: We studied 40 patients previously determined via coronary angiography as having NCA and 40 patients with CSF in the coronary blood stream, as identified by thrombolysis in myocardial infarction square. Thus, a total of 80 patients from the Elazig Education and Research Hospital (Elazig, Turkey) were included in the present study retrospectively and laboratory and anamnesis information was scanned into their files. The relationship between MPV and CSF was studied. RESULTS: MPV levels were observed to be significantly higher in the CSF group compared to the NCA group (10.05±1.3 and 8.6±0.6, p<0.001). In receiver operating characteristics analyses, it was determined that an MPV >9.05 measured in CSF patients at application had a predictive specificity of 77.5% and sensitivity of 77.5% for CSF (area under the curve: 0.825, 95% confidence interval [CI]: 0.726-0.924, p<0.0001). It was found that MPV level was an independent predictor of CSF (ß=-600, p<0.001, 95% CI: -0.383 to -0.176). CONCLUSION: MPV is increased in patients with CSF when compared to patients with NCA. This finding supports the fact that MPV could be a predictor of CSF.

Could neutrophil/lymphocyte ratio be an indicator of coronary artery disease, coronary artery ectasia and coronary slow flow?

Objective To determine whether neutrophil/lymphocyte ratio (NLR) differed between patients with isolated coronary artery disease (CAD), isolated coronary artery ectasia (CAE), coronary slow flow and normal coronary anatomy. Methods Patients who underwent coronary angiography were consecutively enrolled into one of four groups: CAD, coronary slow flow, CAE and normal coronary anatomy. Results The CAD ( n = 40), coronary slow flow ( n = 40), and CAE ( n = 40) groups had similar NLRs (2.51 ± 0.7, 2.40 ± 0.8, 2.6 ± 0.6, respectively) that were significantly higher than patients with normal coronary anatomy ( n = 40; NLR, 1.73 ± 0.7). Receiver operating characteristics demonstrated that with NLR > 2.12, specificity in predicting isolated CAD was 85% and sensitivity was 75%, with NLR > 2.22 specificity in predicting isolated CAE was 86% and sensitivity was 75%. With NLR > 1.92, specificity in predicting coronary slow flow was 89% and sensitivity was 75%. Multivariate logistic regression analyses identified NLR as an independent predictor of isolated CAE (ß = -0.499, 95% CI -0.502, -0.178; P < 0.001), CAD (ß = -0.426, 95% CI -1.321, -0.408; P < 0.001), and coronary slow flow (ß = -0.430, 95% CI -0.811, -0.240; P = 0.001 Table 2 ). Conclusions NLR was higher in patients with CAD, coronary slow flow and CAE versus normal coronary anatomy. NLR may be an indicator of CAD, CAE and coronary slow flow.

Atrial electromechanical conduction delay in patients with neurocardiogenic syncope.

AIM: We aimed to investigate the presence of atrial electromechanical conduction delay in patients with neurocardiogenic syncope, which was diagnosed with head-up tilt table test (HUTT). MATERIALS AND METHODS: A total of 29 patients (mean age: 30.6 ± 15.9 years) with vasovagal syncope, as diagnosed by HUTT, and 23 healthy control subjects (mean age: 34.7 ± 16.3 years) with a negative HUTT were enrolled to the study. Atrial electromechanical conduction delay was defined as the time elapsed from the beginning of the P wave in the electrogardiogram to the beginning of the Am wave in tissue Doppler. RESULTS: There was no statistically significant difference between the groups in terms of interatrial conduction delay, whereas the difference was significant with regard to the right intraatrial electromechanical conduction delay (P < 0.01) and the left intraatrial electromechanical conduction delay (P < 0.0001). There was a negative correlation between the left intraatrial electromechanical conduction delay and the right intraatrial electromechanical conduction delay (r = -0.486, P = 0.001), whereas a positive correlation was present with the interatrial electromechanical conduction delay (r = 0.507, P = 0.001). CONCLUSION: In this study, the tissue Doppler method revealed that there is left and right intraatrial electromechanical conduction delay in patients with vasovagal syncope. The impact and role of atrial conduction delay as a pathophysiological determinant should be confirmed in further studies.

Myocardial Performance Index in Neurocardiogenic Syncope Patients.

BACKGROUND: Many syncopes resulting from neural reflexes in various conditions are called neurocardiogenic syncope (NCS). We aimed to investigate the presence of left ventricular (LV) myocardial performance index (MPI) in patients with NCS, which was diagnosed with head-up tilt table test (HUTT), and the accurateness of the test in order to use it as a method in patients with NCS. Assuming the MPI as a potential cause of syncope, we assessed the Tei index with non-invasive tissue Doppler echocardiography method. METHODS: Consecutive outpatients with a history of recurrent unexplained syncope underwent HUTT. Twenty-nine HUTT (+) patients (24 female and five male, mean age: 30 ± 15 years) as the study group and HUTT (-) 23 healthy patients (six female and 17 male, mean age: 34 ± 16 years) as the control group were included into the study. Conventional and tissue Doppler echocardiography was performed to both groups. The MPI was determined by using PW Doppler. Measurements of Doppler time intervals, according to Tei index ((isovolumic contraction time + isovolumic relaxation time)/ejection time) is calculated as (a - b/b), where "a" is the interval between cessation and onset of the mitral inflow, and "b" is the ejection time (ET) at the LV outflow. RESULTS: When comparing the groups in terms of MPI and ET, there was significant difference between groups. Patients with NCS had significantly longer ET and lower MPI value than control group (284 ± 24 ms vs. 260 ± 24 ms, P < 0.001, respectively and 0.44 ± 0.7 vs. 0.52 ± 0.8, P < 0.001, respectively). There was no significant difference in ejection fraction between groups. CONCLUSION: In the present study, LV MPI value decreases in patients with NCS.

Impact of rheumatic mitral stenosis on aortic elastic properties.

BACKGROUND AND AIM OF THE STUDY: Although mitral stenosis has profound effects on the circulation and hemodynamics, few data exist regarding its impact on aortic elastic properties. The study aim was to determine the association between mitral stenosis and aortic elastic properties by using strain and distensibility as a surrogate. METHODS: Sixty-six patients with echocardiographic documentation of rheumatic mitral stenosis, and 25 age- and gender-matched healthy control subjects were enrolled in the study. Aortic elasticity parameters including strain and distensibility were measured by means of echocardiography. RESULTS: The mean age of the patient and control groups were 41.8 +/- 12.0 and 38.9 +/- 5.0 years, respectively (p = 0.12). There was a significant impairment in distensibility and strain in the patient group compared to controls (0.276 +/- 0.167 versus 0.491 +/- 0.260 cm2 x dyn(-1), p = 0.001; 6.54 +/- 3.18% versus 9.19 +/- 4.78%, p = 0.015). There was a strong correlation between distensibility and left atrial diameter (p < 0.001; r = -0.39), left atrial volume index (p < 0.001; r = -0.56), mitral valve area (p < 0.001; r = 0.40), and mean transmitral gradient (p = 0.022; r = -0.18). Strain was also associated with left atrial diameter (p = 0.002; r = -0.32), left atrial volume index (p < 0.001; r = -0.41), mitral valve area (p = 0.002; r = 0.31), and mean transmitral gradient (p = 0.035; r = -0.18). CONCLUSION: Mitral stenosis was shown to be associated with impaired aortic elasticity, but further studies are required to clarify the clinical significance of this finding.