The predictive value of plasma osmolality for in-hospital mortality in patients with acute pulmonary embolism.

INTRODUCTION AND OBJECTIVES: Prior studies demonstrated that plasma osmolality may have a predictive value for in-hospital mortality in patients with heart failure and acute coronary syndrome. In addition, plasma glucose and blood urea nitrogen (BUN) levels, the components of plasma osmolality, have been shown to be an important contributor for in-hospital mortality in acute pulmonary embolism (APE) patients. Hence, the objective of the current study is to evaluate the effect of plasma osmolality upon admission with in-hospital mortality in patients with APE. METHODS: A total of 245 consecutive intermediate or high risk APE patients were enrolled into the study. The study population was divided into three tertile groups (T1, T2 and T3) based on the increased plasma osmolality. The in-hospital mortality was the primary end-point. RESULTS: After adjusting for all risk factors, in-hospital mortality was significantly higher in the T3 group compared to T1 and T2 groups (OR: 3.6, 95% CI: 1.3 to 18.8, P < .001). In addition, the incidence of asystolia, hypotension and cardiogenic shock were significantly higher in the T3 group. An area under the receiver operating characteristic curve value of plasma osmolality for the in-hospital mortality was 0.76 with sensitivity 67.2% and specificity 74.1% 95% CI: (0.66-0.87, P < .001). CONCLUSION: This is the first study to demonstrate that elevated levels of plasma osmolality may have a predictive value for in-hospital mortality in APE patients. Our findings are novel and deserve further studies whether the treatment of higher plasma osmolality may reduce the risk of in-hospital mortality in APE patients.

Long term evaluation of electromechanical delay in patients with atrial septal defect after transcatheter closure.

Some studies have been showed that electromechanical delay, which may pose an increased tendency to atrial fibrillation, may prolong in patients with various clinical conditions. In addition, the electromechanical delay in patients with secundum type atrial septal defect (ASD) compared to healthy people have been reported previously. Therefore, in the present study, we prospectively evaluated the mid-term and long-term effects of the transcatheter closure of secundum type ASD on the lateral atrial conduction time (PA), septal PA, tricuspid PA, left and right intra-atrial electromechanical delay (ILeft-EMD and IRight-EMD, respectively) and inter-atrial electromechanical delay (IA-EMD) measured by means of Doppler echocardiography. Our prospective study included a total of 45 secundum type ASD patients who undergone percutaneous transcatheter closure from December 2012 to April 2015. All patients underwent transthoracic echocardiography (TTE) before the closure, at sixth and twelfth months after the closure. In comparison of the EMD sixth months after the device closure, there were statistically significant decrease in lateral PA, septal PA, tricuspid PA, ILeft-EMD, IRight-EMD and IA-EMD compared to pre-device closure values. Twelfth months after the device closure, we also observed statistically significant decrease in lateral PA, septal PA, tricuspid PA, ILeft-EMD, IRight-EMD and IA-EMD compared to 6-month post-device closure values. In the present study, we observed that the atrial EMD improves after device closure and continues to improve after twelfth month following post-device closure.

Acute myocardial infarction associated with clomiphene citrate in a young woman.

Clomiphene citrate is a drug that stimulates ovulation and is commonly used in cases of female infertility. Generally, it is recognized as a safe agent for ovulation induction, but rarely, it is associated with life-threatening conditions. A 36-year-old woman who had been prescribed clomiphene citrate for infertility was admitted to the emergency department for chest pain lasting for 2 hours. She had no history of smoking, and she did not have any cardiac risk factor for myocardial infarction (MI). An electrocardiogram performed on admission revealed ST-elevation in the precordial leads. She was taken to the catheter laboratory for ST-elevation myocardial infarction, and the coronary angiography revealed total occlusion of the midportion of the left anterior descending artery (LAD) with a heavy thrombus burden. The circumflex and right coronary arteries were normal. After balloon dilatation, a 2.75x15-mm drug eluting stent was implanted in the mid part of the LAD. The patient had an uncomplicated recovery. Before discharge, echocardiography revealed apical akinesis; anterior and lateral hypokinesis; and an ejection fraction of 45% with mild mitral regurgitation. Although clomiphene citrate is a relatively safe drug for ovarian stimulation, it has been associated with serious side effects, such as MI. Physicians should be aware of the potential risks of clomiphene citrate, especially in patients with risk factors for coronary artery disease.

Is Troponin really a reliable marker in patients with acute ischemic stroke?

BACKGROUND AND PURPOSE: Cardiac troponin I (cTnI) is a reliable marker to diagnose acute myocardial infarction, but the pathophysiological explanation for the increase in cTnI levels in patients with acute ischemic stroke (IS) remains unknown. To overcome this question, we aimed to compare serum cTnI levels in acute coronary syndrome (ACS) concomitant with and without stroke. By doing like this, we thought that we could demonstrate the effect of stroke on TrpI level. METHODS: Serum cTnI levels of 41 patients having ACS with acute IS during hospitalization were compared with 97 control patients having only ACS. Cranial CT was performed to evaluate the lesions. The severity of IS was evaluated objectively by national institutes of health stroke scale. RESULTS: cTnI levels were found to be similar in both groups. Presence of diabetes mellitus, coronary artery disease and previous myocardial infarction were more frequent in patients with acute IS. The cTnI levels in the patients with the cranial lesion in the anterior circulation was higher (p = 0.039). Presence of acute IS, cTnI level higher than 20 ng/mL and left ventricular ejection fraction < 40% were found to be independent risk factors for mortality (p < 0.05). CONCLUSIONS: We found that abnormal troponin levels were more likely to be due to cardiac causes than cerebral ones in this first study evaluating the cTnI levels in patients with ACS concomitant with acute IS. The severity of IS, lesion location in the anterior circulation and higher troponin levels were associated with mortality.

A novel prognostic indicator for in-hospital and 4-year outcomes in patients with pulmonary embolism: TIMI risk index.

BACKGROUND: Thrombolysis in Myocardial Infarction (TIMI) risk index (TRI) was recently evaluated in patients with acute myocardial infarction and found as an important prognostic index. In the current study, we evaluated the prognostic value of TRI in patients with moderate-high and high risk pulmonary embolism (PE) who were treated with thrombolytic agents. METHODS: We retrospectively evaluated the in-hospital and long-term (4-year) prognostic impact of TRI in a total number of 456 patients with moderate-high and high risk PE. Patients were stratified by quartiles (Q) of admission TRI. RESULTS: In-hospital analysis revealed significantly higher rates of in-hospital death for patients with TRI in Q4. After adjustment for confounding baseline variables, TRI in Q4 was associated with 2.8-fold hazard of in-hospital death. Upon multivariate analysis, admission TRI in Q4 vs. Q1-3 was associated with 3.1 fold hazard of 4-year mortality rate. CONCLUSION: TRI in Q4, as compared to Q1-3, was significantly predictive of short term and long-term outcomes in PE patients who treated with thrombolytic agents. Our data suggest TRI to be an independent, feasible, and cost-effective tool for rapid risk stratification in moderate-high and high risk PE patients who treated with thrombolytic agents.

Relation of the Number of Parity to Left Ventricular Diastolic Function in Pregnancy.

Left ventricular diastolic dysfunction (LVDD) has been relatively less studied than other cardiac changes during pregnancy. Previous studies revealed a mild diastolic deterioration during pregnancy. However, these studies did not evaluate the long-term effect of parity on left ventricular diastolic function. A comprehensive study evaluating the long-term effect of parity on diastolic function is required. A total of 710 women with various number of parity were evaluated through echocardiography to reveal the status of diastolic function. Echocardiographic parameters were compared among the women by parity number and categorized accordingly: none, 0 to 4 and 4< parity (grand multiparous). In nulliparous group, 19 women (23.2%) had grade 1 LVDD, and only 2 women (2.4%) had grade 2 LVDD. In women with a parity number of 0 to 4, 209 women (38.3%) had grade 1 LVDD, and only 17 women (3.1%) had grade 2 LVDD. In grand multiparous group, only 2 women (2.4%) did not have LVDD, and 12 women (14.6%) had grade 2 LVDD. None of the subjects had grade 3 or grade 4 LVDD. According to hierarchical logistic regression analysis, any grade of LVDD and grade 2 LVDD had the highest rates at parity category of > 4 parity and that had 21 and 5.8 times higher than nulliparous group, respectively. In conclusion, according to the present study, grand multiparity but not multiparity, severely deteriorates left ventricular diastolic function. Further studies are warranted to evaluate the risk of gradual diastolic dysfunction after each pregnancy.

Long-Term Antiarrhythmic Effects of Thrombolytic Therapy in Pulmonary Embolism.

BACKGROUND: The role of thrombolytic therapy in acute pulmonary embolism patients is still controversial considering the occurrence of arrhythmias. Short-term effects of thrombolytics are well-known whereas long-term effects on cardiac electrophysiology have not been reported before. The objective of our study was to assess the arrhythmic differences in pulmonary embolism patients who received thrombolytics followed by anticoagulation or anticoagulation alone. METHODS: Sixty patients who received thrombolytic therapy followed by anticoagulation (group 1) and 60 patients who received anticoagulation alone (group 2) were included in this retrospective, single-centre observational study. Twenty-four-hour ambulatory electrocardiography was performed 31 ± 9 months after pulmonary embolism hospitalisation in order to compare arrhythmias originating from both ventricles and atria. RESULTS: The age and gender distribution of the patients were statistically similar. Ventricular arrhythmias were found to be the same between t-PA and non t-PA groups. All types of atrial arrhythmias were found to be increased in non t-PA group even though left and right atrial volume indexes were statistically identical between the two groups. CONCLUSION: In long-term pulmonary embolism, follow-up thrombolytic therapy was demonstrated to have atrial antiarrhythmic effects.

The association of blood urea nitrogen levels with mortality in acute pulmonary embolism.

BACKGROUND: The aim of this study was to investigate the association of BUN levels with in-hospital and long-term adverse clinical outcomes in acute pulmonary embolism (APE) patients treated with tissue-plasminogen activator (t-PA). METHODS: This retrospective study included 252 consecutive confirmed APE patients treated with t-PA. An admission BUN of 34.5 mg/dL was identified through an ROC analysis as an optimal cutoff value to predict the in-hospital mortality with 85% sensitivity and 91% specificity (AUC: 0.91; 95% CI: 0.84-0.96; P<.001). RESULTS: Our study showed that an increase in BUN levels was independently associated with a high risk of in-hospital all-cause mortality, low admission systolic blood pressure, use of inotropic drugs, and cardiogenic shock. In-hospital mortality rates were 51.1% in higher BUN group, and 1.9% in lower BUN group (P<.001). CONCLUSION: In this study, elevated admission BUN level was found to be a predictor of all-cause in-hospital mortality. BUN testing is commonly part of the basic metabolic panel; and it can be used to detect high-risk patients with APE, and it bears little risk, is inexpensive, and easy to perform.

A Young Male Patient With Multiple Thromboembolisms Associated With Factor V Leiden Mutation.

Factor V Leiden (FVL) mutation is the most common hereditary thrombophilia. Association of this mutation with venous thrombosis is well established. However, there are several conflicting results regarding the association of FVL with arterial thrombosis, acute coronary syndrome, and intracardiac thrombosis. In this case report, we present a 44-yearold male patient with a medical history of both arterial and venous thrombosis who came to our emergency department with chest pain. After the initial evaluation he was diagnosed as having acute coronary syndrome and transthoracic echocardiography revealed an intracardiac apical thrombus. Coronary angiography showed non-critical stenosis. Thrombophilia panel was studied and the patient was found to be heterozygotic for FVL mutation. An apical thrombus was extracted surgically because of the high risk of systemic embolization.

A Retained Bullet in Pericardial Sac: Penetrating Gunshot Injury of the Heart.

Penetrating cardiac trauma is rarely seen but when present there is a short time lag to keep the patients alive. Cardiac gunshot injuries are exceptional and it occurs mostly during interpersonal disagreements casualties or a mistakenly fired gun nowadays. Here we present a case of cardiac gunshot injury from the war of Kobani, Syria. The patient was mistakenly diagnosed to have a sole bullet in the left shoulder while he had a penetrating cardiac trauma with a bullet in the heart and pericardial effusion possibly giving rise to pericardial tamponade. Luckily the cardiac gunshot injury was noticed one day later and the patient was referred to a tertiary hospital. Intrapericardial bullet was conservatively followed up. The patient was discharged one week later after resection of the bullet in the shoulder.

Admission Glucose Level Predicts In-hospital Mortality in Patients with Acute Pulmonary Embolism Who Were Treated with Thrombolytic Therapy.

BACKGROUND: Elevated admission serum glucose level is associated with unfavourable clinical outcomes in various clinical conditions. The aim of this study was to investigate the relationship between admission glucose levels and in-hospital and long-term adverse clinical outcomes in patients with pulmonary embolism (PE) treated with thrombolytic therapy. METHODS: A total of 183 consecutive confirmed acute PE patients (98 female and 85 male; mean age 61.9 ± 15.7 years) who were treated with thrombolytic therapy enrolled in this study. The study population was categorised into four quartiles according to admission serum glucose levels (group I: glucose ≤115 mg/dl; group II: glucose >115-141 mg/dl; group III: glucose >141-195 mg/dl; and group IV: glucose ≥196 mg/dl). RESULTS: In-hospital mortality was significantly higher in group IV (28.8 %) compared to group III (15.2 %), group II (6.6 %), and group I (2.1 %) (p < 0.001). In multivariate analysis, admission glucose level (OR 1.013, 95 % CI 1.004-1.021, p = 0.004) and admission anaemia (OR 0.602, 95 % CI 0.380-0.955, p = 0.03) were independent predictors of in-hospital mortality. The mean follow-up period was 34 months. During long-term follow-up, all-cause mortality, recurrent PE, major and minor bleeding were similar among the four groups. CONCLUSION: Admission glucose level is a simple, inexpensive, easily available, and effective laboratory parameter for predicting in-hospital mortality in patients with PE.

Sublingual vs. Oral Captopril in Hypertensive Crisis.

BACKGROUND: There are confusing data in literature regarding oral and sublingual captopril effects over blood pressure (BP) decrease. OBJECTIVES: In our study we compared oral and sublingual captopril effectiveness over BP decrease in patients admitted to our Emergency Department with hypertensive urgency. METHODS: Our study was conducted from January 2012 to January 2013 in patients with hypertensive urgency. In this cross-sectional study after two initial BP measurements, patients were identified as eligible for the study. An initial electrocardiogram was obtained and blood samples were drawn. A total of 212 patients were accepted as eligible for the study, and 25 mg of captopril was randomly given orally or sublingually; BP was measured at 10, 30, and 60 min. We selected the patients to the groups consecutively. A 25% reduction of initial BP 1 h after initiation of the treatment was accepted as an accomplishment. A second 25 mg of captopril was given if the target of 25% reduction of BP was not reached after the first tablet. Intravenous drugs were administered to the patients resistant to the captopril and these patients were excluded from the study. RESULTS: The 10-min systolic BP (SBP), diastolic BP, and mean BP (MBP) decrease was more prominent in the sublingual captopril group (p < 0.001). This decrease was statistically significant in the SBP and MBP at 30 min (p < 0.001), and no statistical difference was recorded at 60 min (p > 0.05). CONCLUSIONS: In our study, sublingual captopril was found to decrease BP more efficiently in the first 30 min, but this difference equalized at 60 min.

Admission serum potassium level is associated with in-hospital and long-term mortality in ST-elevation myocardial infarction.

OBJECTIVE: Current guidelines recommend a serum potassium (sK) level of 4.0-5.0 mmol/L in acute myocardial infarction patients. Recent trials have demonstrated an increased mortality rate with an sK level of>4.5 mmol/L. The aim of this study was to figure out the relation between admission sK level and in-hospital and long-term mortality and ventricular arrhythmias. METHODS: Retrospectively, 611 patients with ST-elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention were recruited. Admission sK levels were categorized accordingly: <3.5, 3.5-<4, 4-<4.5, 4.5-<5, and ≥5 mmol/L. RESULTS: The lowest in-hospital and long-term mortality occurred in patients with sK levels of 3.5 to <4 mmol/L. The long-term mortality risk increased for admission sK levels of >4.5 mmol/L [odds ratio (OR), 1.58; 95% confidence interval (CI) 0.42-5.9 and OR, 2.27; 95% CI 0.44-11.5 for sK levels of 4.5-<5 mmol/L and ≥5 mmol/L, respectively]. At sK levels <3 mmol/L and ≥5 mmol/L, the incidence of ventricular arrhythmias was higher (p=0.019). CONCLUSION: Admission sK level of >4.5 mmol/L was associated with increased long-term mortality in STEMI. A significant relation was found between sK level of <3 mmol/L and ≥5 mmol/L and ventricular arrhythmias.

Creatinine kinase isoenzyme-MB: A simple prognostic biomarker in patients with pulmonary embolism treated with thrombolytic therapy.

BACKGROUND: Creatinine kinase isoenzyme-MB (CK-MB) is a biomarker for detecting myocardial injury. The aim of this study was to evaluate the association between admission CK-MB levels and in-hospital and long-term clinical outcomes in pulmonary embolism (PE) patients treated with thrombolytic tissue-plasminogen activator. METHODS: A total of 148 acute PE patients treated with tissue-plasminogen activator enrolled in the study. The study population was divided into 2 tertiles, based on admission CK-MB levels. The high CK-MB group (n=35) was defined as having a CK-MB level in the third tertile (>31.5 U/L), and the low group (n=113) was defined as having a level in the lower 2 tertiles (≤31.5 U/L). RESULTS: High CK-MB group had a higher incidence of in-hospital mortality (37.1% vs 1.7%, P<.001). Admission systolic blood pressure and tricuspid annular plane systolic excursion were lower in the high CK-MB group. In the receiver-operating characteristic curve analysis, a CK-MB value of more than 31.5 U/L yielded a sensitivity of 86.7% and specificity of 83.5% for predicting in-hospital mortality. During long-term follow-up, recurrent PE, major and minor bleeding, and mortality rates were similar in both groups. CONCLUSION: Creatinine kinase isoenzyme-MB is a simple, widely available, and useful biomarker for predicting adverse in-hospital clinical outcomes in PE.

A case report of coronary artery aneurysm in a patient with Behçet's disease.

Behçet's disease (BD) is a multisystem vasculitis that may involve vessels of all sizes. Acute coronary syndrome (ACS) due to secondary involvement of BD is rare and its management less clear. In this case, a 29-year-old man admitted to the emergency room with ongoing chest pain was interned to the coronary care unit with a diagnosis of ACS. The patient had been diagnosed 1 year before with BD and had been without regular follow-up, despite the suggested use of cholchium. An immediate coronary angiography revealed a fresh thrombus image in the proximal segment of the right coronary artery (RCA), an aneurysm of the left anterior descending artery (LAD) at proximal segment, and a hemodynamically significant lesion following the aneurysm. Intervention was ended because of normal flow (TIMI III) of distal RCA. An intravenous infusion of glycoprotein IIb/IIIa receptor inhibitor (tirofiban) was administered, and a control angiography showed dissolution of a thrombus in RCA, but enlarged aneurysm of LAD and a new aneurysm in RCA.

Subfoveal choroidal thickness in patients with chronic heart failure analyzed by spectral-domain optical coherence tomography.

PURPOSE: To evaluate the subfoveal choroidal thickness (SFCT) measured by enhanced depth imaging optical coherence tomography (EDI-OCT) in eyes of chronic heart failure (CHF) patients. METHODS: Fifty-six patients with CHF and 56 age- and gender-matched healthy individuals were enrolled. The SFCT was measured by EDI-OCT. The ejection fraction of left ventricle (EFLV), age, intraocular pressure (IOP), axial length (AL), systolic and diastolic blood pressure, and ocular perfusion pressure (OPP) were also measured. RESULTS: Mean SFCT was 181.2 ± 80.23 µm in the study group and 283.6 ± 52.4 µm in the control group (p = 0.000). There was a statistically significant correlation between the SFCT and each of EFLV and age. SFCT value was not statistically significantly associated with AL, IOP and OPP. CONCLUSION: Our results suggest that SFCT is lower in eyes of CHF patients compared to age- and gender-matched healthy individuals.