Influence of apelin-12 on troponin levels and the rate of MACE in STEMI patients.

BACKGROUND: During acute myocardial infarction, phosphorylated TnI levels, Ca2+ sensitivity and ATPase activity are decreased in the myocardium, and the subsequent elevation in Ca2+ levels activates protease I (caplain I), leading to the proteolytic degradation of troponins. Concurrently, the levels of apelin and APJ expression are increased by limiting myocardial injury. METHODS: In this prospective observational study, 100 consecutive patients with ST-elevation acute myocardial infarction were included. Patients meeting the following criteria were included in our study: (1) continuous chest pain lasting for >30 min, (2) observation of ST-segment elevation of more than 2 mm in two adjacent leads by electrocardiography (ECG), (3) increased cardiac troponin I levels, and (4) patients who underwent reperfusion therapy. We evaluated the levels of apelin-12 and troponin I on the first and seventh days after reperfusion therapy in all patients. RESULTS: Apelin-12 was inversely correlated with troponin I levels (Spearman's correlation = -0.40) with a p value <0.001. There was variability in the apelin values on the seventh day (Kruskal-Wallis test) based on major adverse cardiac events (MACE) (p = 0.012). Using ROC curve analyses, a cut-off value of >2.2 for the association of apelin with MACE was determined, and the AUC was 0.71 (95% CI, 0.58-0.84). Survival analysis using the Kaplan-Meier method showed a lower rate of MACE among patients with apelin levels >2.2 (p = 0.002), and the ROC curve analysis showed a statistically significant difference in the area under the curve (p = 0.004). CONCLUSION: The influence of apelin levels on troponin levels in the acute phase of STEMI is inversely correlated, whereas in the non-acute phase, low apelin values were associated with a high rate of MACE.

Anomalous Origin of Left Circumflex Artery.

INTRODUCTION: The coronary anatomic variation of the left circumflex artery (LCx) is considered as the most common anatomic variation with a separate ostium from the right sinus, and very unusual variation as a proximal branch of right coronary artery (RCA). CASE REPORT: We report two cases, the first case is a 64-year-old man with chest pain and with history of hypertension, obesity, dyslipidemia and current smoker, and the second case is a 67-year-old who presented to the emergency department with chest pain and with a past medical history of arterial hypertension and type 2 diabetes mellitus. In the coronarography of the first case is detected an ectopic left circumflex coronary artery from the right coronary sinus with stenotic changes in RCA and LCx. The second case in the coronary angiography revealed an ectopic left circumflex coronary artery from the proximal part of the right coronary artery with stenotic changes in LAD, RCA and LCx. Based on guidelines for revascularization our patients successfully underwent treatment procedures. We present two cases that because of the atherosclerotic coronary artery disease leads to the need of coronarography find out the presence of coronary artery anomalies. CONCLUSION: During the coronarography we should think about coronary artery anomaly or missing artery knowing that type of these anomalies, considering that may be a contributing factor in the development of the atherosclerosis determines the method of the treatment.

Acute myocardial infarction and polycythemia rubra vera: The double effect of treatment with hydroxyurea.

We report a case of acute myocardial infarction in a patient with polycythemia rubra vera, who has been treated with hydroxyurea. The patient presented with chest pain extending to both arms accompanied by nausea and sweating. Hemoglobin was 18.1 mg/dL, hematocrit 53.2%, white blood cells 9600/mm³, and platelets 745,000/mm³. The levels of specific cardiac injury markers were increased, troponin I increased to 110 ng/mL and creatine kinase-MB to 361 U/l, respectively. Electrocardiography showed sinus rhythm with ST-segment elevation in leads V2-6, D1, and aVL as well as ST depression in D2, D3 and aVF. Echocardiography demonstrated hypokinesis of the interventricular septum and lateral wall with mildly reduced left ventricle (LV) ejection fraction (EF≈45%). Coronary angiography revealed proximal-LAD subtotal occlusion and 80% mid-LAD stenosis with distal-LAD vasospasm. Percutaneous coronary intervention was performed with a drug-eluting stent in mid- and proximal-LAD. Hypercoagulable state of polycythemia rubra vera may be complicated with acute myocardial infarction, in addition to the vasospastic effect and endothelium lesions of hydroxyurea regardless its favorable effect as a standard therapy.

Quadricuspid Aortic Valve and Rheumatoid Arthritis: A Coincidence or Interconnection.

Quadricuspid aortic valve is a very rare congenital anomaly. Its association with rheumatoid arthritis is exceptional with this being the third case reported in the literature. We report a case of a 52 year old female patient with quadricuspid aortic valve type C accompanied by moderate to severe aortic regurgitation and longstanding, advanced form of rheumatoid arthritis. Having refused surgical aortic valve intervention 4 years ago, the patient is currently under a watchful follow-up strategy. The patient received a diagnosis of rheumatoid arthritis over 15 years before and presently has serious deformities in the hands, legs, feet, and spine. In conclusion, quadricuspid aortic valve and rheumatoid arthritis together are extremely rare. While it is possible that this association is coincidental, considering the genetic background of both disorders, there is a potential for them to be interconnected comorbidities. This report is the first to highlight the association between the 2 disorders.

Primary percutaneous coronary intervention on split left coronary artery: Two case reports.

The split left coronary artery (LCA) is an anomaly of coronary arteries connection related to the aorta, presenting more often in patients who underwent invasive coronary angiography compared to coronary computed tomography angiography. Although this anomaly causes no hemodynamic impairment, failure to recognize may lead to incorrect diagnosis and prolonged procedures during acute myocardial infarction resulting in serious complications. We report 2 cases of split left coronary artery presenting with acute myocardial infarction who underwent primary percutaneous coronary interventions (pPCI) with excellent outcomes. In the both cases, electrocardiogram demonstrated ST-segment elevation and cardiac biomarkers were increased. Also, before coronary angiography in both patients echocardiographic examination was performed revealing hypokinesis who corresponded with the territory of occluded coronary arteries. During invasive further coronary examinations split left artery was found, besides the culprit lesion in the left anterior descending artery (LAD). Successful percutaneous stenting was performed on LAD achieving TIMI flow grade 3 in both cases. Prompt recognition of split LCA in the setting of acute myocardial infarction during pPCI, it is essential to achieve appropriate treatment and avoid potential clinical consequences.

Association between apelin-12 and creatine kinase-MB, depending on success of reperfusion in STEMI patients.

BACKGROUND: Acute myocardial infarction is characterised by an imbalance in the supply and demand of oxygen in the heart. It requires urgent reperfusion, and poor outcomes are attributed to myocardial ischaemia-reperfusion injury. We aimed to evaluate the association between apelin-12 levels and creatine kinase-MB activity in predicting the effectiveness of reperfusion therapy in ST-segment elevation myocardial infarction (STEMI) patients. METHODS: In this study we included 72 patients with the following criteria: chest pain suggestive of myocardial ischaemia for at least 30 minutes, an electrocardiogram with ST-segment elevation (measured at the J-point) ≥ 2 mm in leads V2-V3 and/or ≥ 1 mm in the other leads, rise of specific biomarkers such as cardiac troponin and the MB fraction of creatine kinase (CK-MB), and those who underwent reperfusion therapy. Blood samples for the measurement of apelin-12 and creatine kinase-MB were collected 12 hours after the reperfusion therapy. RESULTS: In patients with thrombolysis in myocardial infarction (TIMI) flow grade ≤ 2, the median of the apelin-12 level was 1.80 ng/ml (0.46-9.20), and with TIMI flow 3, it was 5.76 ng/ml (1.14-15.2). Variability was observed in the apelin values (Mann-Whitney test) based on TIMI flow grade (p < 0.001), while no variability was observed for creatine kinase-MB (p < 0.18). The degree of association between apelin-12 and creatine kinase-MB levels was analysed with Pearson's correlation, enabling us to determine patients with successful reperfusion (determined as TIMI flow 3) (p < 0.004), and those with unsuccessful reperfusion (with TIMI flow ≤ 2) (p = 0.86). CONCLUSION: In STEMI patients undergoing reperfusion therapy, Apelin-12 level was associated with creatine kinase-MB activity according to the success of the reperfusion.

Large intercoronary communication between the right coronary artery and the left circumflex artery in a patient with late stent thrombosis: A case report.

Intercoronary communication (ICC) is a very rare coronary artery anomaly that connects directly 2 coronary arteries. This anastomosis is found between 2 nonobstructed coronary arteries with unidirectional or bidirectional blood flow. We report a case of a large ICC between the right coronary artery and the left circumflex artery in a patient with late stent thrombosis. The electrocardiogram showed ST-segment elevation in the anterior leads. The echocardiography investigation revealed hypokinesis in the proximal, medial and apical segments of the interventricular septum and anterior wall as well as the apex. During invasive coronary examination a large ICC between the left circumflex artery (LCx) and the right coronary artery (RCA) was found. Furthermore, coronary angiography demonstrated proximal occlusion (stent thrombosis) of the left anterior descending artery (LAD), prompting the utilization of percutaneous intervention with a drug-eluting stent. The presence of a large intercoronary communication is an exceedingly uncommon anomaly of the coronary arteries, which has the potential to induce myocardial ischemia. In individuals with obstructive coronary artery disease, this anomaly can further worsen the existing condition.

Coronary to pulmonary artery fistula associated with significant coronary atherosclerosis and severe aortic valve stenosis: A Case Report.

Coronary artery fistulas are anomalous connections between one or two coronary arteries with either a cardiac chamber or any major blood vessels (coronary sinus, superior vena cava, pulmonary veins and pulmonary artery). It is rarely reported, occurring only in 0.1%-0.2% of patients who undergo coronary angiography. We report a very rare case where myocardial ischaemia may have resulted from the presence of coronary artery fistula, significant coronary artery stenosis and severe aortic valve stenosis. Transthoracic echocardiography showed severe aortic stenosis, while coronary angiography showed a tortuous coronary artery fistula originating from the proximal left anterior descending artery, with a single opening in the main pulmonary artery. Angiography also showed significant stenosis in the middle of the left anterior descending artery. Coronary artery fistula with concomitant significant coronary atherosclerosis and severe aortic stenosis requires optimal therapeutic planning.

A Case of Successfully Implanted Dual Chamber Pacemaker in a Young Patient with Dextrocardia and Sick Sinus Syndrome.

Dextrocardia is a rare congenital anomaly, whereas its association with sick sinus syndrome in young adults without accompanying heart abnormalities is exceptional. We report a case of a 38 year old female patient who was admitted to our hospital due to syncope as a consequence of sinus pauses up to 4.9 seconds. She was also diagnosed with situs inversus totalis, with mirror image dextrocardia. Pacemaker implantation was indicated. Under local anesthesia, from the left subclavian vein, the guide wire was passed through superior vena cava to the right atrium and ventricle without any obstacles. In conclusion, situs inversus totalis with mirror image dextrocardia may present in combination with sick sinus syndrome as early as the fourth decade of life. Implantation of pacemaker leads from the left subclavian vein appears accessible and safe in patients with dextrocardia with situs inversus (mirror image).

Size of Acute Myocardial Infarction Correlates with Earlier Time of Initiation of Reperfusion Therapy with Cardiac Perfusion Scintigraphy: A National Single-Center Study.

BACKGROUND The aim of this study was to determine the correlation between the size of acute myocardial infarction (AMI) and the time of initiation of reperfusion therapy with cardiac perfusion scintigraphy. MATERIAL AND METHODS Overall, 80 patients with acute ST elevation myocardial infarction (STEMI) were examined. All patients were treated with primary percutaneous coronary intervention (pPCI). Data on patient and system delay expressed in minutes were recorded and compared with recommended timelines. Cardiac scintigraphy was performed with 99m Tc-sestamibi single-photon emission computed tomography (SPECT). The median time of cardiac scintigraphy was 20 days. The correlation between the size of infarction and the time of initiation of reperfusion therapy was evaluated. RESULTS The mean age of patients was 60.5±11.5 years, and 72.5% were male. The average system delay was 348 min, and the average patient delay was 173 min. The mean total ischemic time was 800 min. There was a correlation between time delays of reperfusion therapy and infarct size. Patients with a shorter time delay to patent artery after FMC showed smaller infarct size when compared to the patients with longer delay times. Multiple linear regression analysis showed that FMC, being male, and smokers had statistical significance when predicting infarct size. CONCLUSIONS There is a correlation between the size of myocardial infarction and the time of initiation of reperfusion therapy determined by perfusion myocardial scintigraphy. The study showed that there are time delays in starting the treatment of AMI with pPCI when compared to the recommended time, which requires an action plan in the near future to ensure earlier treatment for our patients.

Predictors of Spontaneous Echo Contrast in Left Heart Chambers in Patients with Dilated Cardiomyopathy: Slowing Down Might not Always Mean Enjoying Life.

INTRODUCTION: Spontaneous echo contrast(SEC) is usually detected in heart chambers as a result of reduced flow velocity in the cavity. The clinical importance of SEC lies in its association with embolic events. The aim of our study was to determine the frequency of SEC in left heart chambers in sinus rhythm patients with dilated cardiomyopathy and predictors for its emergence. MATERIALS AND METHODS: This was a prospective cross-sectional transesophageal echocardiography study conducted in 101 sinus rhythm patients with dilated heart and mild-to-moderate systolic dysfunction. RESULTS: Moderate-degree SEC was found in the left ventricle(LV) in around 9% of patients, in the left atrium(LA) in 12% and in left atrial appendage(LAA) in 40%. Multiple regression analysis showed that lower heart rate(95% confidence interval[CI]: 0.845-0.978; P = 0.011) and larger LV end-systolic diameter(LVESD)(95% CI: 1.034-1.394; P = 0.017) were independent predictors for LV SEC presence. Lower LV ejection fraction(LVEF) (95% CI: [-0.079]-[-0.037]; P = 0.0001) was the only independent predictor for SEC in the LA. Whereas, independent predictors for SEC in LAA were lower heart rate(95% CI:[-0.030]-[-0.003]; P = 0.018), greater LA indexed diameter (95% CI: 0.016-0.116; P = 0.010), and higher value of C-reactive protein(CRP)(95% CI: 0.0026-0.031; P = 0.027). CONCLUSIONS: SEC in left heart chambers is a frequent finding in patients with dilated cardiomyopathy in sinus rhythm. Lower heart rate and LVEF, larger LVESD and LA, as well as higher CRP, predict the presence of SEC in left heart chambers. Lower heart rate might be an essential predictor for SEC presence and severity in these patients.

Catheter Left Main Dissection Bailout Treatment with Stenting.

BACKGROUND: Iatrogenic left main coronary artery dissection is a rare complication during invasive coronary procedures. Prompt action is needed avoiding acute pump failure followed with hemodynamic collapse and fatal results. CASE REPORT: We report a 48-year-old woman who underwent bail-out stenting. CONCLUSION: The best therapeutic strategy depends upon the prompt recognition of this complication, hemodynamic condition of the patient and operative skills. The therapeutic strategy by bail-out stenting should be performed in most cases of severe dissection toward good outcomes.

Immature teratoma mimicking pulmonary stenosis: a case report.

BACKGROUND: Immature teratoma in a mediastinal location is a rare disease that might present as a valve pathology. Germ cell tumors with mediastinal locations account for up to 6% of immature teratoma cases. We present a case of an immature teratoma located primarily in the anterior mediastinum that manifested solely through symptoms of pulmonary stenosis. CASE PRESENTATION: We report a case of a 20-year-old white man with an immature teratoma who presented with progressive exertional dyspnea. During a cardiac examination, an ejection systolic murmur was observed, and echocardiography findings at an Emergency Centre revealed high velocity flow at the level of the pulmonary artery, indicating pulmonary stenosis. He was hospitalized in our Cardiology Department for further investigation. A chest X-ray revealed a mediastinal mass, and repeated echocardiography indicated the presence of a large mediastinal mass compressing his main pulmonary artery. Magnetic resonance imaging confirmed the tumor in the mediastinum, and a histopathological diagnosis of immature teratoma was established following biopsy. CONCLUSION: Immature teratoma causing cardiac-related complaints might shift the diagnosis toward cardiovascular diseases, thus requiring prompt examination by standard and sophisticated methods to clarify the diagnosis.

Ectopic Origin of Coronary Arteries Diagnozed by Coronary Angiography.

INTRODUCTION: Anomalous origin of coronary arteries from opposite sinus of Valsalva is rare finding. The incidence of anomalous origination of the left coronary artery from right sinus is 0.15% and the right coronary artery from the left sinus is 0.92%. The ectopic origin of left coronary artery or right coronary artery from opposite sinus depending on pathways and considering atherosclerotic changes are manifested with different clinical significance. CASE REPORT: We report two cases, the first case the coronary angiography showed the left coronary artery arising from the right coronary sinus, presenting with proximally and distally stenosed left anterior descending artery (LAD), associated with medial and distal stenosed right coronary artery (RCA). The second case the coronary angiography revealed the right coronary artery arising from the left coronary sinus, associated with tortuous medial and distal segments of left anterior descending artery (LAD), without atherosclerotic changes. The first case successfully underwent treatment procedures based on guidelines for revascularization. CONCLUSION: The coronary angiography of patients with coronary ischemia determines atherosclerotic disease with possibility of the presence of coronary artery anomalies that in cases with ectopic origin from opposite sinus continues to exist as a challenge during treatment in interventional cardiology.

Atrioventricular septal defect with common atrioventricular junction guarded by a common valve consisting of left atrioventricular trifoliate valve.

INTRODUCTION: Atrioventricular septal defect with common atrioventricular junction is a rare adult congenital cardiac syndrome. This occurrence with prolonged survival is exceptionally rare. CASE REPORT: We present the case of a patient who presented with this defect with common atrioventricular junction who survived to the age of 32. We describe a 32-year-old man with atrioventricular septal defect with common atrioventricular junction guarded by a common valve. His history, clinical course, and anatomic findings are discussed along with the factors which may have contributed to his longevity, which is unique in the medical literature. His management reflected the state of medical knowledge at the time when he presented, and although alternate approaches may have been utilized if the patient presented today. We discuss the findings, frequency, classifi cation, and management of congenital defects. Development of embryonic structure is altered by interaction between genetics and environmental factors toward a rare associated of congenital cardiac defects-complex congenital heart disease. CONCLUSION: This case demonstrates that patients with very complex congenital cardiac disease may survive to adulthood, presenting challenges in both medical and surgical treatment.

Age-related Epstein-Barr virus-positive cutaneous ulcer arising after a self-limited subcutaneous abscess: a case report.

INTRODUCTION: Epstein-Barr virus-positive mucocutaneous ulcer is a newly recognized clinicopathologic entity in the spectrum of Epstein-Barr virus-positive lymphoproliferative disorders. This entity is characterized by a self-limited, indolent course. CASE PRESENTATION: We report the case of a 74-year-old, type 2 diabetic man who presented with an ulceroinfiltrative skin lesion on the left side of his neck. Histological examination showed that the lesion consisted of large atypical cells, some with Hodgkin-Reed-Sternberg-like morphology, in the midst of reactive lymphocytes, plasma cells, eosinophils and histiocytes. The atypical cells were partially positive for CD45, CD20, CD79a, CD30, B-cell lymphoma 2 and latent membrane protein 1 (CS.1-4), and negative for CD15, B-cell lymphoma 6 and CD10. In situ hybridization for Epstein-Barr virus-encoded ribonucleic acid was positive. Two years before, the patient had been diagnosed with a self-limited subcutaneous abscess in the same anatomic area that healed after antibiotic therapy. CONCLUSION: Older patients with positive Epstein-Barr virus serology may develop B-cell lymphoproliferations due to age-related immune suppression. Epstein-Barr virus-encoded ribonucleic acid testing and clonality analysis, eventually complemented with close clinical follow-up, should be performed for suspicious inflammatory lesions in older patients.

Limitations of CHADS2 scoring system in predicting stroke risk--need to change the age criteria.

INTRODUCTION: Atrial fibrillation (AF) is the most common arrhythmia with a strong association with age. The aim of this study was to evaluate the rate of stroke in relation to age and anticoagulation status based on CHADS2 risk criteria. METHODS: This study included all patients with non-valvular atrial fibrillation admitted to our clinic between 1/11/2007 and 1/11/2009, with minimum one year follow up for patients without stroke. We calculated risk based on CHADS2 (C-cardiac failure, H- hypertension, A-age >75 years, D-diabetes mellitus, S-stroke) point system and evaluated anticoagulation status at the moment of first occurrence of stroke. We observed the rate of stroke in different group age. RESULTS: The average of participants with AF was 67.9 +/- 10.3 years. Amongst 302 patients with non-valvular atrial fibrillation, 32.5% had been anticoagulated while 13.9% of experienced stroke. The stroke were more present in patients who used aspirin in age group 65-74 (22.5%, P = 0.014). The mean age of patients who experienced stroke were 67.2, SD +/- 10.8 vs. 71.6, SD +/- 5.1, P = 0.000. Of the patients with stroke from age group 65-74 years, 23 were in CHADS2 0-1 scoring system. CONCLUSION: The higher rate of stroke was in the 65-74 years age group, with CHADS2 scoring system 0-1, and without anticoagulation therapy. Therefore modification has to be considered for the CHADS2 scoring system to account the age as a risk factor for population in different regions.

The impact of acute myocardial infarction on left ventricular systolic function.

BACKGROUND: During acute myocardial infarction left ventricular systolic function is an important prognostic factor whose worsening is still frequent despite the therapeutic approach. We aimed to estimate the incidence of left ventricular systolic dysfunction among patients experiencing acute myocardial infarction. METHODS: The study involved 154 consecutive patients admitted at Coronary Care Unit. The study design was based upon the collection of patient histories, clinical examination and other complementary tests. RESULTS: In overall study population, predominantly with male gender, the incidence of left ventricle systolic dysfunction was 42.3%, which correlated with myocardial damage, electrocardiography changes, myocardial enzymes, and myocardial wall motion. CONCLUSIONS: Transthoracic Echocardiography represents a valuable tool and left ventricular ejection fraction should be evaluated in all patients experiencing acute myocardial infarction since the incidence of left ventricular dysfunction in patients with Acute Myocardial Infarction remains relatively high.

Cardiac and pulmonary alterations in patients with rheumatoid arthritis.

INTRODUCTION: cardiac and pulmonary clinical manifestations frequently absent in patients with rheumatoid arthritis (RA). The aim of this study was to evaluate cardiac and pulmonary alterations in RA among patients without clinical manifestations. MATERIALS AND METHODS: The study was conducted in 169 patients (127 female and 42 male, with mean age 51.6, SD +/- 12.7 years, P > 0.05) with RA diagnosed on the basis of ACR criteria. All patients underwent a transthoracal echocardiography (TTE), a chest X ray, an electrocardiogram and laboratory tests. Patients with clinical manifestations of cardiac and pulmonary disease were excluded from the study. RESULTS: Pericarditis was evidenced in 16.6%, mitral regurgitation in 21.9%, aortal regurgitation in 26%, and pulmonary diffuse fibrosis in 16.6% of cases The authors found that 158 (93.5%) of patients were CRP positive. CONCLUSION: Our study demonstrated that cardiac and pulmonary alterations are frequently present and prevalence of elevated CRP levels and positive serologic tests was high in asymptomatic patients with RA among patients without clinical manifestations.

Poststaphylococcal coagulase negative reactive arthritis: a case report.

We report a case of a 49-year-old patient who developed poststaphylococcal coagulase negative reactive arthritis. The woman presented with constitutional symptoms, arthritis, urinary infection and conjunctivitis. The blood culture was positive for the staphylococcal coagulase negative infection. Erythrocyte sedimentation rate and C-reactive protein were elevated, whereas the rheumatoid factor was negative. Radiographic findings confirmed diagnosis of pleuropneumonia, and one year later of chronic asymmetric sacroileitis. Physicians should be aware of possible reactive arthritis after staphylococcal coagulase negative bacteremia.