The Effect of Aortic Angulation on Clinical Outcomes of Patients Undergoing Transcatheter Aortic Valve Replacement.

INTRODUCTION: The aim of this study was to assess the impact of aortic angulation (AA) on periprocedural and in-hospital complications as well as mortality of patients undergoing Evolut™ R valve implantation. METHODS: A retrospective study was conducted on 264 patients who underwent transfemoral-approach transcatheter aortic valve replacement with self-expandable valve at our hospital between August 2015 and August 2022. These patients underwent multislice computer tomography scans to evaluate AA. Transcatheter aortic valve replacement endpoints, device success, and clinical events were assessed according to the definitions provided by the Valve Academic Research Consortium-3. Cumulative events included paravalvular leak, permanent pacemaker implantation, new-onset stroke, and in-hospital mortality. Patients were divided into two groups, AA ≤ 48° and AA > 48°, based on the mean AA measurement (48.3±8.8) on multislice computer tomography. RESULTS: Multivariable logistic regression analysis was performed to identify predictors of cumulative events, utilizing variables with a P-value < 0.2 obtained from univariable logistic regression analysis, including AA, age, hypertension, chronic renal failure, and heart failure. AA (odds ratio [OR]: 1.73, 95% confidence interval [CI]: 0.89-3.38, P=0.104), age (OR: 1.04, 95% CI: 0.99-1.10, P=0.099), hypertension (OR: 1.66, 95% CI: 0.82-3.33, P=0.155), chronic renal failure (OR: 1.82, 95% CI: 0.92-3.61, P=0.084), and heart failure (OR: 0.57, 95% CI: 0.27-1.21, P=0.145) were not found to be significantly associated with cumulative events in the multivariable logistic regression analysis. CONCLUSION: This study demonstrated that increased AA does not have a significant impact on intraprocedural and periprocedural complications of patients with new generation self-expandable valves implanted.

Comparison of Evolut-R 34 mm Valve and Smaller Evolut-R Valves in Patients Undergoing Transcatheter Aortic Valve Implantation and Determination of Mild Paravalvular Leak Predictors.

OBJECTIVE: The main purpose of this study was to evaluate and compare the in-hospital, 1-month and 1-year post-procedure outcomes of patients treated with Evolut-R 34 mm and Evolut-R 23/26/29 mm devices. Additionally, the study aimed to identify factors that could predict the occurrence of ≥ mild paravalvular leaks (PVL). METHODS: Between April 2015 and May 2022, 269 consecutive patients who underwent transcatheter aortic valve implantation (TAVI) with Evolut-R 34 mm (n = 66, 24.5%) and Evolut-R 23/26/29 mm (n = 203, 75.5%) devices in a single center were retrospectively analyzed. RESULTS: Patients in the Evolut-R 34 mm group had a lower female sex ratio (16.7% vs. 66.5%, P <.001, respectively), ejection fraction (50.7 ± 10.1% vs. 54.5 ± 9.3%, P =.016, respectively), and mean aortic gradient (7.4 ± 3.3 vs. 9.2 ± 5.0, P =.026, respectively) compared to the Evolut-R 23/26/29 mm group. The groups did not exhibit any statistically significant distinctions with regard to technical success, the need for a permanent pacemaker, occurrences of stroke, major vascular complications, PVL, major adverse cardiovascular and cerebrovascular events, or mortality. Peak velocity was confirmed as a significant predictor of ≥mild PVL in both patient groups in the receiver operating characteristic curve analysis. In logistic regression analysis; In patients with Evolut-R 34 mm valve, pre-TAVI aortic valve peak velocity (odds ratio (OR) = 23.202; P =.019) and calcium volume 800 Hounsfield Units (mm3) (OR = 1.017; P <.001) were independent predictors of ≥mild PVL. CONCLUSION: The Evolut-R 34 mm valve has shown comparable in-hospital results with smaller valve sizes. Pre-TAVI aortic valve peak velocity and calcium volume predicted ≥ mild PVL in Evolut-R 34 mm patients.

The effect of body mass index on complications in cardiac implantable electronic device surgery.

BACKGROUND: Cardiac implantable electronic device (CIED) procedures are prone to complications. In our study, we investigated the effect of body mass index (BMI) on CIED-related complications. METHODS: 1676 patients who had undergone CIED surgery (de novo implantation, system upgrade, generator change, pocket revision or lead replacement) at two heart centers in Turkey and met the study criteria were included in our study. For analysis of primary and secondary endpoints, patients were classified as non-obese (BMI < 25 kg/m2 ), overweight (25 ≤ BMI < 30 kg/m2 ), and obese (BMI ≥ 30 kg/m2 ). The primary endpoint was accepted as cumulative events, including the composite of clinically significant hematoma (CSH), pericardial effusion or tamponade, pneumothorax, and infection related to the device system. Secondary outcomes included each component of cumulative events. RESULTS: The rate of cumulative events, defined as primary outcome, was higher in the obese patient group, and we found a significant difference between the groups (3.0%, 4.3%, 8.9%, p = .001). CSH and pneumothorax rates were significantly higher in the obese patient group (0.3%, 0.9%, 1.9%, p = .04; 1.0%, 1.4%, 3.3%, p = .04, respectively). According to our multivariate model analysis; gender (OR:1.882, 95%CI:1.156-3.064, p = .01), hypertension (OR:4.768, 95%CI:2.470-9.204, p < .001), BMI (OR:1.069, 95%CI:1.012-1.129, p = .01) were independent predictors of cumulative events rates. CONCLUSIONS: Periprocedural complications associated with CIED (especially hematoma and pneumothorax) are more common in the group with high BMI.

Effect of the Prognostic Nutrition Index on Long-Term Outcomes in Unprotected Left Main Coronary Artery Revascularization.

Objective    The prognostic nutritional index (PNI) is a practical, applicable, prognostic scoring system. However, its clinical significance in unprotected left main coronary artery (ULMCA) patients undergoing percutaneous coronary intervention (PCI) has not yet been clarified. This study aimed to examine the relationship between malnutrition as assessed by PNI and major adverse cardiac events (MACE) in ULMCA patients undergoing PCI.Material and methods    185 patients who were hospitalized in our clinic underwent coronary angiography, had a critical LMCA lesion, and underwent angiography-guided PCI were included. The study population was divided into tertiles based on the PNI values. A high PNI (n=142) was defined as a value in the third tertile (≥ 34.0), and a low PNI (n=43) was defined as a value in the lower 2 tertiles (< 34.0). The primary endpoint was MACE.Results    MACE and mortality rates in the low PNI group were significantly higher compared to the high PNI group (51 % vs. 30 %, p=0.009; 44 % vs. 20 %, p=0.002, respectively). High PNI (HR:1.902; 95 % CI:1.112-3.254; p=0.019), previous stroke (HR:3.025; 95 % CI:1.038-8.810; p=0.042) and SYNTAX score (HR:1.028; 95 % CI:1.004-1.057, p=0.023) were independent predictors of MACE in the multivariable cox regression analyzes.Conclusions    In patients undergoing ULMCA PCI, nutritional status can be considered an indicator of MACE rates by evaluating the PNI score. This index can be used for risk classification.

The effect of treatment strategy on long-term follow-up results in patients with nonvalvular atrial fibrillation in Turkey: AFTER-2 subgroup analysis.

BACKGROUND: We performed a subanalysis of the data from the AFTER-2 registry. In our study, we aimed to compare the long-term follow-up results of nonvalvular atrial fibrillation (NVAF) patients in Turkey according to their treatment strategies. METHODS: All consecutive patients older than 18 years of age who presented to cardiology outpatient clinics, had at least one AF attack and did not have rheumatic mitral valve stenosis or prosthetic heart valve disease were included in our prospective study. The patients were divided into two groups as rhythm control and rate control. Stroke, hospitalization and death rates were compared between the groups. RESULTS: A total of 2592 patients from 35 centers were included in the study. Of these patients, 628 (24.2%) were in the rhythm control group and 1964 (75.8%) in the rate control group. New-onset ischemic cerebrovascular disease or transient ischemic attack (CVD/TIA) was detected at a lower rate in the rhythm control group (3.2% vs. 6.2% p = 0.004). However, there was no significant difference in one-year and five-year mortality rates (9.6% versus 9.0%, p = 0.682 and 31.8% versus 28.6%, p = 0.116, respectively). Hospitalization were found to be significantly higher in patients with rhythm control group (18% vs. 13%, p = 0.002). CONCLUSION: It was found that rhythm control strategy is preferred in AF patients in Turkey. We found a lower rate of ischemic CVD/TIA in patients in the rhythm control group. Although no difference was observed in mortality rates, we found a higher rate of hospitalization in the rhythm control group.

Evaluation of Hematological Parameters After Transcatheter Aortic Valve Replacement.

Although transcatheter aortic valve replacement (TAVR) is safe and effective, mortality and bleeding events post procedure are important. The present study investigated the changes in hematologic parameters to evaluate whether they predict mortality or major bleeding. We enrolled 248 consecutive patients (44.8% male; mean age 79.0 ± 6.4 years) undergoing TAVR. In addition to demographic and clinical examination, blood parameters were recorded before TAVR, at discharge, 1 month and 1 year. Hemoglobin levels before TAVR 12.1 ± 1.8 g/dL, 10.8 ± 1.7 g/dL at discharge, 11.7 ± 1.7 g/dL at first month, 11.8 ± 1.4 g/dL at first year (Hemoglobin values compared with pre-TAVR, P < .001, P = .019, P = .047, respectively). Mean platelet volume (MPV) before TAVR 8.72 ± 1.71 fL, 8.16 ± 1.46 fL at discharge, 8.09 ± 1.44 fL at first month, 7.94 ± 1.18 fL at first year (MPV values compared with pre-TAVR, P < .001, P < .001, P < .001, respectively). Other hematologic parameters were also evaluated. Hemoglobin, platelet count, MPV, and red cell distribution width before the procedure, at discharge, and at the first year did not predict mortality and major bleeding in receiver operating characteristic analysis. After multivariate Cox regression analysis, hematologic parameters were not independent predictors of in-hospital mortality, major bleeding, and death at 1 year after TAVR.

Comparison of the real-life clinical outcomes of warfarin with effective time in therapeutic range and non-vitamin K antagonist oral anticoagulants: Insight from the AFTER-2 trial.

BACKGROUND: It is unclear whether warfarin treatment with high time in therapeutic range (TTR) is as effective and safe as non-vitamin K antagonist oral anticoagulants (NOACs). It is crucial to compare warfarin with effective TTR and NOACs to predict long-term adverse events in patients with atrial fibrillation. AIMS: We aimed to compare the long-term follow-up results of patients with atrial fibrillation (AF) who use vitamin K antagonists (VKAs) with effective TTR and NOACs. METHODS: A total of 1140 patients were followed at 35 different centers for five years. During the follow-up period, the international normalized ratio (INR) values were studied at least 4 times a year, and the TTR values were calculated according to the Roosendaal method. The effective TTR level was accepted as >60% as recommended by the guidelines. There were 254 patients in the effective TTR group and 886 patients in the NOAC group. Ischemic cerebrovascular disease/transient ischemic attack (CVD/TIA), intracranial bleeding, and mortality were considered primary endpoints based on one-year and five-year follow-ups. RESULTS: Ischemic CVD/TIA (3.9% vs. 6.2%; P = 0.17) and intracranial bleeding (0.4% vs. 0.5%; P = 0.69), the one-year mortality rate (7.1% vs. 8.1%; P = 0.59), the five-year mortality rate (24% vs. 26.3%; P = 0.46) were not different between the effective TTR and NOACs groups during the follow-up, respectively. The CHA2DS2-VASC score was similar between the warfarin with effective TTR group and the NOAC group (3 [2-4] vs. 3 [2-4]; P = 0.17, respectively). Additionally, survival free-time did not differ between the warfarin with effective TTR group and each NOAC in the Kaplan-Meier analysis (dabigatran; P = 0.59, rivaroxaban; P = 0.34, apixaban; P = 0.26, and edoxaban; P = 0.14). CONCLUSION: There was no significant difference in primary outcomes between the effective TTR and NOAC groups in AF patients.

A new trend to reduce adverse events in patients undergoing transcatheter aortic valve implantation: cusp overlap technique: a cross sectional study.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is currently the treatment of choice for the majority of patients at moderate or high surgical risk. However, some complications occur frequently with this procedure. In this study, we aimed to assess whether the cusp-overlap view (COP) technique may be associated with a reduced incidence of some of these complications compared with the classical three-cusp view (TCV) technique. METHODS: In this single-center, retrospective study we investigated; technical success, postprocedural permanent pacemaker implantation (PPMI), new-onset stroke, pericardial tamponade, arrhythmia development, acute renal failure, major bleeding, major vascular complications, procedure-related coronary obstruction, new-onset left bundle branch block (LBBB), paravalvular leak, peri-procedural myocardial infarction (MI), day of hospitalization, death, and major adverse cardiac and cerebrovascular events (MACCE) were determined as the clinical endpoints. RESULTS: A total of 281 consecutive patients who met the study criteria and underwent elective or emergency transfemoral TAVI using the self-expandable CoreValve Evolut valve were included. 176 consecutive patients implanted with the classical TCV technique and 105 consecutive patients implanted with the COP technique were compared. Compared with the TCV group, patients in the COP group had lower PPMI (3.8% vs. 10.8%, p = 0.039), in-hospital mortality (1.9% vs. 8.5%, p = 0.018), and 1-year death (4.8% versus 18.8%, p = 0.001), and MACCE rates (12.4% vs 31.3%, p < 0.001). CONCLUSION: The COP technique may help to reduce the conduction disturbances, PPMI requirement and complication rates that may develop following TAVI. In addition, it is an interesting result that it reduces mortality and MACCE rates in long-term follow-ups.

Oral Anticoagulant Use and Long-Term Follow-Up Results in Patients with Non-valvular Atrial Fibrillation in Turkey AFTER-2 Study.

BACKGROUND: The aim of this study was to investigate the frequency of oral anticoagulant drugs and time in therapeutic range in patients receiving warfarin in addition to the epi-demiological trial of non-valvular atrial fibrillation previously conducted in Turkey (The Atrial Fibrillation: Epidemiological Registry trial). Furthermore, the prevalence of major adverse events and mortality rates of the patients were evaluated during the long-term follow-up period. METHODS: We created a national data registry for non-valvular atrial fibrillation patients, reflecting all geographic regions by population density. In that context, the study included all consecutive atrial fibrillation patients older than 18 years of age who were admitted to the cardiology outpatient clinic except for patients those with prosthetic heart valvesand rheumatic mitral valve stenosis. RESULTS: This study included 2592 patients from 35 different centers. The mean age was 68.7 ± 11.1 years, and 55.5% of the patients were female. The most common comorbid diseases were chronic kidney disease (69%) and hypertension (65.5%). The time in ther- apeutic range rate in the general population was 40%, and the mortality rate at 5-year follow-up was 29.4%. CONCLUSION: The Atrial Fibrillation: Epidemiological Registry 2 study showed higher use of anticoagulant in non-valvular atrial fibrillation patients than in previous national stud-ies. Furthermore, this study demonstrated that most of the non-valvular atrial fibrilla- tion patients are in the high-risk group and the time in therapeutic range rates are still low in Turkey. As a result, this is a significant reason for switching from warfarin to non-K vitamin-dependent new oral anticoagulant treatments.

Impact of the recovery of left ventricular ejection fraction after TAVI on mortality in patients with aortic stenosis.

OBJECTIVE: To assess the effects of transvalvular aortic valve implantation (TAVI) on the outcomes of the patients with symptomatic severe aortic stenosis (AS), and predict the effect of left ventricular ejection fraction (LVEF) and cardiac structural recovery on mortality after the TAVI in patients with different stage of LV function. METHODS: Out of 191 patients, 151 consecutive patients in 3 centers were evaluated for outcome analysis. Patients were classified into 3 subgroups as AS with reduced ejection fraction (ASrEF) (LVEF <40%), AS with mildly reduced EF (ASmrEF) (LVEF 40-49%) and AS with preserved EF (ASpEF) (LVEF ≥50%). RESULTS: The mean follow-up period was 19.4±12.4 (up to 54) months. All-cause mortality was not different among all 3 groups. (p=0.901). In multivariate analysis, stroke volume index (SVI) (Exp(B): 0.039, 95% confidence interval [CI]: 0.011-0.013, p<0.001), baseline blood urea nitrogen (Exp(B): 1.022, 95% CI: 1.006-1.038, p=0.006), and percent LVEF change after TAVI (d-LVEF) (Exp(B): 0.046, 95% CI: 0.004-0.610, p=0.046) were the independent predictors for mortality after TAVI. The receiver operating characteristic curve analysis showed that the cutoff value of "≤10%" for d-LVEF had sensitivity of 50%, specificity of 75%, and an area under the curve of 0.72 in predicting mortality in patients with SVI <35 mL/m2. CONCLUSION: Improvement of LVEF after TAVI, which reflected the marked LV reverse remodeling, has an impact on the prediction of the survival in patients with AS, and this is more prominent in patients with low SVI.

A child case of Kawasaki with giant coronary aneurysm: percutaneous coronary intervention due to anterior myocardial infarction.

Kawasaki disease is usually self-limited, but it can lead to aneurysm, stenosis, thrombosis, and myocardial infarction in the coronary arteries. The most important complication of Kawasaki disease is coronary artery aneurysm. Coronary artery aneurysm or ectasia may be seen in 15-25% of patients who do not receive treatment. It develops in 5% of children who receive intravenous immunoglobulin at the appropriate time. Acute myocardial infarction is the most important cause of morbidity and mortality in Kawasaki patients with giant aneurysms. We present a 10-year-old girl who had a history of giant aneurysm in the coronary arteries and underwent percutaneous coronary intervention due to anterior myocardial infarction.

Predictive Value of C-Reactive Protein to Albumin Ratio in ST-Segment Elevation Myocardial Infarction Patients Treated With Primary Percutaneous Coronary Intervention.

The present study aimed to examine the association of C-reactive protein to albumin ratio (CAR) with short-term major adverse cardiac events (MACEs) in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI). We included 539 STEMI patient treated with pPCI in this study. Patients were divided into 2 groups according to MACE development. Patients with MACE had higher CAR than those without (1.18 [0.29-1.99] vs 0.21 [0.09-0.49], P < .001). Multivariate analysis showed that The Global Record for Acute Coronary Events score, Percutaneous Coronary Intervention with TAXus and cardiac surgery (SYNTAX) score, glucose and CAR (odds ratio:1.326, 95% CI: 1.212-1452, P < .001) were independent predictors of MACE. The CAR may be proven useful for risk stratification in STEMI patients undergoing pPCI.

Post transcatheter aortic valve replacement ejection fraction response is predictor of survival among patients with whole range of systolic dysfunction.

AIMS: The objective of this study is to assess the prognostic effects of T ranscatheter aortic valve replacement (TAVR) on the patients with different degrees of left ventricular systolic (LVS) function and severe symptomatic aortic stenosis. Also examines the prognostic association of LV remodelling after TAVR. METHODS AND RESULTS: Patients stratified into four subgroups with respect to baseline LV ejection fraction (LVEF) (LVEF > 25%, LVEF 25%-40%, LVEF 41%-49% and LVEF ≥ 50%). We compared the baseline characteristics and temporal changes in echocardiographic parameters of the patients after TAVR, and determined all-cause mortality (ACM) in a follow-up period of mean 20.7 ± 15.8 months (up to 84). There were 495 patients at 8 centres. ACM was similar in all groups (28.1%, 29.5%, 22.5% and 24.1% respectively; p = .44). Immediately after TAVR, there was an improvement in LVEF (from 38.7 ± 9.4 to 44.9% ± 10.9%, p < .001). The percent change in LVEF (pDelta-EF) immediately after TAVR was more prominent in the patients with LVEF < 25% (48.1 ± 49.6, 21.9 ± 29.6), (8.4% ± 15.2%) and (2.1 ± 7)) (p < .01). Importantly, a 12% increase in absolute Delta-EF was observed in patients with LVEF< 25% with 100% sensitivity and 42.5% specificity for the prediction of ACM. CONCLUSION: This study shows that TAVR is beneficial in the whole range of LVS function, irrespective of the baseline EF. Early recovery in LVEF after TAVR is critical for survival, however, it seems to be more eye catching in the patients with advanced heart failure with reduced EF.

The Ratio of Fibrinogen to Albumin as a Predictor of Contrast-Induced Nephropathy After Carotid Angiography.

Contrast-induced nephropathy (CIN) is acute kidney failure that occurs after exposure to contrast agent. There is no sensitive biomarker to predict the development of CIN. In a retrospective study, we investigated the predictive value of the fibrinogen to albumin ratio (FAR) to determine the risk of CIN in patients (N = 246) who underwent carotid angiography. Contrast-induced nephropathy was defined as a 0.5 mg/dL or 25% increase in serum creatinine levels 48 to 72 hours following exposure to a radiocontrast agent. Patients were grouped according to whether they developed CIN or not, that is, CIN(-) and CIN(+) groups, respectively. Contrast-induced nephropathy developed in 39 (15.8%) of all the patients. The fibrinogen levels, neutrophil to lymphocyte ratio (NLR), and FAR in the CIN (+) group were higher than in the CIN (-) group ( P < .001). Multivariate analysis showed that age, diabetes, NLR, platelet-lymphocyte ratio, and FAR were independent risk factors for CIN. The area under the curve (AUC) of FAR was 0.800 for the prediction of CIN, and the best cutoff value was 57.4 with sensitivity, specificity, positive predictive value, and negative predictive value of 74.4%, 60.8%, 26.4%, and 92.7%, respectively. The FAR may be useful as a predictor of CIN.

The utility of the TIMI risk index on admission for predicting angiographic no-reflow after primary percutaneous coronary intervention in patients with STEMI.

BACKGROUND/AIM: The thrombolysis in myocardial infarction (TIMI) risk score (TRS), and the TIMI risk index (TRI) have been reported in coronary artery disease patients. We investigated whether admission TRI is associated with no-reflow (NRF) in patients undergoing primary percutaneous coronary intervention (p-PCI). MATERIALS AND METHODS: ST-segment elevation myocardial infarction (STEMI) patients treated with p-PCI were included in the study. TRI was calculated on admission using specified variables. We defined the angiographic NRF phenomenon as a coronary TIMI flow grade of ≤2 after the vessel was recanalized or a TIMI flow grade of 3 together with a final myocardial blush grade (MBG) of <2 in a manner as described in previous studies. RESULTS: A total of 371 patients (aged 62 ± 14 years; 73/27 men to women ratio) who underwent p-PCI were enrolled in the study. In terms of age, NRF patients were older than reflow patients (P < 0.017 for MBG). Killip class III-IV designations were more common in NRF patients (P = 0.029 for MBG). TRI (P = 0.014 for MBG) values were significantly greater in the NRF group. TRI was an independent predictor of NRF according to MBG flow (P = 0.003, B = -0.035, Exp B = 0966, 95% CI, 0.944-0.988). CONCLUSION: Admission TRI may predict the development of NRF phenomenon after p-PCI in patients with acute STEMI.

The relationship between fibrinogen to albumin ratio and severity of coronary artery disease in patients with STEMI.

OBJECTIVE: Previous studies show that serum fibrinogen levels are established risk factors for coronary artery disease (CAD) and that serum albumin levels are of a higher specificity and sensitivity in ST-elevation myocardial infarction (STEMI). In this study, we sought to evaluate the association between fibrinogen to albumin ratio (FAR) and the extent and severity of CAD evaluated by TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries (SYNTAX) Score (SS) in patients with STEMI. METHODS: A total of 278 patients with STEMI were included in the study. FAR was calculated using specified variables. The extent and severity of CAD were evaluated using the SS. The patients were divided into low- (SS <22) and high- (SS ≥22) risk groups. A Spearman rank correlation coefficient analysis was used for the relationship between FAR and SS. The cutoff points for sensitivity and specificity of FAR in predicting SS were estimated by performing a receiver operator characteristic curve analysis. RESULTS: There were significant differences in the mean age (P=.016), admission serum albumin (P=.041), serum fibrinogen (P<.001), FAR (P<.001), and SS risk groups. Positive correlation was detected between FAR and SS (r=0.458, P<.001). A cutoff level of >87 FAR predicted SS (sensitivity, 70%; specificity, 70%), and an area under the curve of 0.758 serum fibrinogen and albumin level was an independent predictor for SS in patients with STEMI (b=0.039; 95% confidence interval, 0.016-0.062; P=.001 and b=-6.906; 95% confidence interval, -12.284 to -1.527; P=.013, respectively). CONCLUSION: In the present study, we showed that FAR is significantly related to SS in predicting the severity of CAD in patients with STEMI.