The Relationship between Coronary Flow Reserve and the TyG Index in Patients with Gestational Diabetes Mellitus.

Background and Objectives: Gestational diabetes mellitus (GDM) is a prevalent metabolic disorder characterized by glucose intolerance during pregnancy. The triglyceride glucose (TyG) index, a marker of insulin resistance, and coronary flow reserve (CFR), a measure of coronary microvascular function, are emerging as potential indicators of cardiovascular risk. This study aims to investigate the association between CFR and the TyG index in GDM patients. Materials and Methods: This cross-sectional study of 87 GDM patients and 36 healthy controls was conducted. The participants underwent clinical assessments, blood tests, and echocardiographic evaluations. The TyG index was calculated as ln(triglycerides × fasting glucose/2). CFR was measured using Doppler echocardiography during rest and hyperemia induced by dipyridamole. Results: The study included 87 individuals in the GDM group and 36 individuals in the control group. There was no significant difference in age between the two groups (34.1 ± 5.3 years for GDM vs. 33.1 ± 4.9 years for the control, p = 0.364). The TyG index was significantly higher in the GDM group compared to the controls (p < 0.001). CFR was lower in the GDM group (p < 0.001). A negative correlation between the TyG index and CFR was observed (r = -0.624, p < 0.001). Linear regression revealed the TyG index as an independent predictor of reduced CFR. Conclusions: The study findings reveal a significant association between the TyG index and CFR in GDM patients, suggesting their potential role in assessing cardiovascular risk.

The importance of apoptotic activity and plasma NT-proBNP levels in patients with acute exacerbation of decompensated heart failure and their relation to different drugs and comorbidities.

OBJECTIVE: To demonstrate the presence and importance of apoptotic activity in heart failure during acute exacerbations and to investigate the effects of different drugs used and co-morbidities on levels of N-Terminal pro-Brain Natriuretic Peptide and apoptotic activity on admission and during hospitalisation. METHODS: The descriptive study was conducted at the emergency department of Istanbul University Cardiology Institute between October 2010 and May 2011 and comprised patients with complaints of shortness of breath, and who were evaluated as acutely exacerbated decompensated heart failure with an aetiology of ischaemic or dilated cardiomyopathy. Apoptotic activity and N-Terminal pro-Brain Natriuretic Peptide levels were measured on admission and on the seventh day of treatment. SPSS 15 was used for statistical analysis. RESULTS: Of the 89 patients in the study, 67(75%) were males. Overall mean age of the study sample was 61 +/- 12 years. Patients who had N-Terminal pro-Brain Natriuretic Peptide levels higher than 6000 pg/ml on admission had greater in-patient mortality rate (p < 0.001). N-Terminal pro-Brain Natriuretic Peptide levels decreased significantly on the seventh day of treatment compared to the admission values (p < 0.012). Apoptotic activity levels, although not statistically significant, increased on the seventh day compared with admission values (p < 0.12). Apoptotic activity levels on the 7th day were associated with in-patient deaths (p < 0.002). Dopamine infusion in the treatment group during hospitalisation significantly increased apoptotic activity (p < 0.035), whereas there was a trend towards decreased apoptotic activity levels with spironolactone (p < 0.07). Treatment with beta-blockers did not change apoptotic activity levels (p < 0.751), whereas lack of beta-blocker therapy increased apoptotic activity (p < 0.02). CONCLUSION: N-Terminal pro-Brain Natriuretic Peptide may be an important risk predictor in decompensated heart failure exacerbations during hospatilasation but not apoptotic activity. Beta-blocker therapy seems to positively affect the process of apoptosis.

Cardiac tamponade due to left ventricular pseudoaneurysm after aortic valve replacement.

Left ventricular outflow tract pseudoaneurysm is a rare but a potentially lethal complication, mainly after aortic root endocarditis or surgery. Usually, it originates from a dehiscence in the mitral-aortic intervalvular fibrosa and arises posteriorly to the aortic root. We report a rare case of a patient with cardiac tamponade due to left ventricular pseudoaneurysm after aortic valve replacement. The subsequent surgical resection was performed successfully.

A case of renal artery embolism treated by selective intra-arterial infusion of tissue plasminogen activator.

Thromboembolic obstruction of the renal artery is a serious clinical problem, but rarely diagnosed. The diagnosis is not usually established until irreversible renal parenchymal damage occurs. Here, we present a case of renal artery thromboembolism in a patient who had atrial fibrillation and was treated by selective intra-arterial infusion of tissue plasminogen activator (TPA). A 69-year-old male was admitted to our hospital with a one-hour history of palpitation and epigastric pain. He had inferior myocardial infarction and percutaneous coronary intervention to the right coronary artery two weeks before. Coronary angiogram was performed, and no significant stenosis was detected. One hour later, epigastric pain spread to the left flank region. Spiral computerized tomography showed occlusion of the left renal artery. Emergency abdominal angiography was performed, and selective intra-arterial infusion of TPA was started promptly. The abdominal pain disappeared, and urine output remained adequate. Forty-eight hours later, angiographic follow-up confirmed the complete lysis of the thrombus in the left renal artery. No renal or hemorrhagic complications were observed, and the patient was discharged four days later with normalized renal function on oral anticoagulation.

Middle East Treatment Strategies and Clinical Outcomes in Patients with Atrial Fibrillation: One-Year Follow-up Data from Garfield-AF Study.

INTRODUCTION: The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) aims to determine real-life treatment patterns and clinical outcomes of patients with newly diagnosed non-valvular atrial fibrillation (AF) and at least one investigator-determined risk factor for stroke. The registry includes a wide array of baseline characteristics and has a particular focus on: (1) bleeding and thromboembolic events; (2) international normalized ratio fluctuations; and (3) therapy compliance and persistence patterns. METHODS: Evolution in baseline treatment for patients enrolled in sequential cohorts showed an increase in prescribing of novel oral anticoagulants over time. Variability in novel oral anticoagulant prescription is primarily due to differences in availability of treatment and prescribing habits between countries and care settings. The GARFIELD-AF registry also provides insights into clinical management and related outcomes of AF in Middle East populations. RESULTS: A total of 1660 patients with non-valvular AF (median age 64.0 years, interquartile range 56.0-72.0), mostly diagnosed in cardiology settings from Egypt, the United Arab Emirates and Turkey, were recruited in cohorts 3-5. Data from patient populations in the Middle East related to the rates of stroke/systemic embolism, major bleeding and all-cause mortality 1 year after diagnosis of AF and treatment strategies, based on the stroke and bleeding risk, have been analysed and compared with the rest of the world. The use of antithrombotic treatment in the Middle East was generally higher than the non-Middle East, with increased prescription of antiplatelet therapy (AP) therapy. Appropriate use of Factor Xa inhibitors/direct thrombin inhibitors (DTIs) were 74.4% and Factor Xa/DTI + APs were 70.4% in the overall population, whereas they were 57.1% and 63.6%, respectively, in the Middle East. CONCLUSION: We have found that rates of stroke and bleeding were lower, although mortality was higher, in the Middle East population. This paper describes the baseline characteristics, patterns of antithrombotic treatment and 1-year outcomes in Middle East AF patients. TRIAL REGISTRATION: http://www.clinicaltrials.gov . Identifier, NCT01090362.

Retained pericardial pellets for 25 years: a case report.

Retained cardiac pellets are clinically silent foreign bodies that do not cause any cardiovascular disturbance. A 71-year-old woman presented with exertional chest pain. Her physical examination and surface electrocardiogram were normal. After a positive treadmill test, coronary angiography was performed which showed nonsignificant coronary lesions. During fluoroscopy, several pellets were observed throughout the neck and two of them were simultaneously moving within the heart shadow. Transthoracic and transesophageal echocardiography showed no evidence for pericardial effusion. Computed tomography scans of the chest showed the pellets above the left diaphragm in the pericardial area. Her past medical history revealed an accidental shot from a pellet rifle by her son 25 years before, at which time no surgical intervention was planned as she had been asymptomatic.

The impact of the new World Symposium on Pulmonary Hypertension definition of pulmonary hypertension on the prevalence of pre-capillary pulmonary hypertension.

OBJECTIVE: Since the first World Symposium on Pulmonary Hypertension (WSPH; Geneva, 1973), pulmonary hypertension (PH) has been defined as a mean pulmonary artery pressure (mPAP) ≥25 mm Hg measured at right heart catheterization (RHC) while at rest in the supine position. At the 6th WSPH congress (Nice, 2018), a new proposal was presented defining pre-capillary PH as mPAP >20 mm Hg, with pulmonary arterial wedge pressure (PAWP) <15 mm Hg, and pulmonary vascular resistance (PVR) >3 WU. The aim of this study was to investigate the impact of the new definition of PH on the number of pre-capillary PH patients. METHODS: The results of RHC performed with various clinical indications between 2017 and 2018 were analyzed. The 2015 European Society of Cardiology (ESC)/European Respiratory Society (ERS) and the 6th WSPH congress PH definitions were used to identify PH patients. RESULTS: Fifty-eight RHC procedures were performed in our hospital in a 1-year period. Most were performed with a suspicion of PH (n=52). The remainder (n=6) were performed with indications of valvular heart disease or left heart disease. There were 40 females (69%) and 18 males (31%). The mean age was 53.3±16.6 years. The RHC results revealed a mean PAP of 36.4±16.4 mm Hg, PAWP of 12.6±3.9 mm Hg, and PVR of 4.9±4.4 WU. Forty-three of 58 patients (74.1%) were classified as pre-capillary PH according to the ESC/ERS PH guideline, whereas 50 of 58 patients (86.2%) had pre-capillary PH according to the new WSPH definition. CONCLUSION: The results of this study indicated that the impact of the new definition of PH on the number of pre-capillary PH patients identified was greater than the predicted <10%.

The association of neutrophil to lymphocyte ratio and TIMI frame count in primary percutaneous coronary intervention.

BACKGROUND: This study was sought to evaluate the relationship between admission neutrophil lymphocyte ratio (NLR) and estimated coronary flow by the TIMI frame count (TFC) method in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). METHODS: TFC of 262 consecutive STEMI patients were evaluated after PPCI. Admission NLR were calculated and TFC was determined after PPCI. According to admission NLR value, patients were divided in to two groups. NLR levels higher than 3.5 were defined "higher NLR" whereas lower than 3.5 were accepted as "lower NLR". RESULTS: TFC was significantly higher in patients with higher NLR (56.6±41.1 vs. 37.9±36.1, P<0.001). No-reflow phenomenon was more frequent in higher NLR group compared to lower NLR group (10.1% vs. 5.2%, P=0.001). In multivariate linear regression analysis admission NLR was an independent predictor of high TIMI frame count (B=2.24 95 % CI (1.17-3.31), P<0.001). CONCLUSIONS: Our findings suggest that admission NLR predicts coronary blood flow in means of TFC.

Antithrombotic treatment patterns and stroke prevention in patients with atrial fibrillation in TURKEY: inferences from GARFIELD-AF registry.

The corner stone of atrial fibrillation therapy includes the prevention of stroke with less adverse effects. The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) study provided data to compare treatment strategies in Turkey with other populations and every-day practice of stroke prevention management with complications. METHODS: GARFIELD-AF is a large-scale registry that enrolled 52,014 patients in five sequential cohorts at >1,000 centers in 35 countries.This study initiated to track the evolution of global anticoagulation practice, and to study the impact of NOAC therapy in AF. 756 patients from 17 enrolling sites in Turkey were in cohort 4 and 5.Treatment strategies at diagnosis initiated by CHA2DS2-VASc score, baseline characteristics of patients, treatment according to stroke and bleeding risk profiles, INR values were analyzed in cohorts.Also event rates during the first year follow up were evaluated. RESULTS: AF patients in Turkey were mostly seen in young women.Stroke risk according to the CHADS2 score and CHA2DS2-VASc score compared with world data. The mean of risk score values including HAS-BLED score were lower in Turkey than world data.The percentage of patients receiving FXa inhibitor with or without an antiplatelet usage was more than the other drug groups. All-cause mortality was higher in Turkey. Different form world data when HAS-BLED score was above 3, the therapy was mostly changed to antiplatelet drugs in Turkey. CONCLUSION: The data of GARFIELD-AF provide data from Turkey about therapeutic strategies, best practices also deficiencies in available treatment options, patient care and clinical outcomes of patients with AF.

Multiple angiomatous mitral valve cysts leading to floppy mitral valve syndrome.

We report an extremely rare case of cystic-tumor like formations that originated from the mitral valve tissue affected by verrucous endocarditis, leading to floppy mitral valve syndrome. These cystic tumoral formations were discovered during two-dimensional echocardiographic examination of a 46 year-old woman with cardiac symptoms of palpitation, dyspnea, and exertional angina pectoris. Multiple cysts were attached to the anterior mitral leaflet, resulting in pansystolic pseudoparachute-like floppy mitral valve prolapse, and severe mitral regurgitation. The patient underwent prosthetic mitral valve replacement following removal of the mitral valve and multiple cystic-tumoral formations. She had an uneventful postoperative course. Histological diagnosis was diffuse angiomatous cystic development of vasculatory tumor-like structures due to verrucous endocarditis.

Relationship between myocardial performance index and severity of coronary artery disease in patients with non-ST-segment elevation acute coronary syndrome.

OBJECTIVES: We aimed to investigate the relationship between myocardial performance index (MPI) and severity of coronary artery disease, as assessed by the Gensini score (GS), in patients with non-ST-segment elevation myocardial infarction (NSTEMI). METHODS: Ninety patients with an initial diagnosis of NSTEMI were enrolled in our study. They were divided into tertiles according to the GS: low GS < 19; mid GS > 19 and ≤ 96; and high GS > 96. RESULTS: The low-, mid- and high-GS groups included 24, 38 and 28 patients, respectively. Clinical features such as gender distribution; body mass index (BMI); prevalence of diabetes mellitus, hypertension and hyperlipidaemia; and smoking status were similar in the three groups. MPI and isovolumic relaxation time were significantly higher in the high-GS group than in the low- and mid-GS groups (p < 0.001 and p = 0.005, respectively). Furthermore, the high-GS group had a significantly lower ejection fraction and ejection time (p = 0.01 and p < 0.001, respectively). MPI was positively correlated with the GS (r = 0.47, p < 0.001), and multivariate regression analysis showed that MPI was an independent predictor of the GS (ß = 0.358, p < 0.001). CONCLUSIONS: Patients with NSTEMI who fall within the high-risk group may be identified by means of a simple MPI measurement.

Impact of continuation of metformin prior to elective coronary angiography on acute contrast nephropathy in patients with normal or mildly impaired renal functions.

OBJECTIVE: Discontinuation of metformin treatment in patients scheduled for elective coronary angiography (CAG) is controversial because of post-procedural risks including acute contrast-induced nephropathy (CIN) and lactic acidosis (LA). This study aims to discuss the safety of continuing metformin treatment in patients undergoing elective CAG with normal or mildly impaired renal functions. METHODS: Our study was designed as a single-centered, randomized, and observational study including 268 patients undergoing elective CAG with an estimated glomerular filtration rate of >60 mL/min/1.73 m2. Of these patients, 134 continued metformin treatment during angiography, whereas 134 discontinued it 24 h before the procedure. CIN was defined as either a 25% relative increase in serum creatinine levels from the baseline or a 0.5 mg/dL increase in the absolute value that measured 48 h after CAG. Logistic regression analysis was performed to identify independent predictors of CIN and LA after CAG. RESULTS: Both groups were comparable in terms of demographics and laboratory values. CIN at 48 h was 8% (11/134) in the metformin continued group and 6% (8/134) in the metformin discontinued group (p=0.265). Patients in neither of the groups developed metformin-induced LA. Based on multiple regression analysis, the ejection fraction [p=0.029, OR: 0.760; 95% CI (0.590-0.970)] and contrast volume [p=0.016, OR: 0.022 95% CI (0.010-0.490)] were independent predictors of CIN. CONCLUSION: Patients scheduled for elective CAG with normal or mildly impaired renal functions and preserved left ventricular ejection fraction (>40%) may safely continue metformin treatment.

Comparison of Long-Term Outcomes in Real-World Patients Between Resolute Zotarilumus-Eluting and Paclitaxel-Eluting Stents in Small Vessel.

OBJECTIVE: To compare the long-term clinical outcomes between Resolute zotarolimus-eluting stent (R-ZES) and paclitaxel-eluting stent (PES) in patients with small coronary artery disease. BACKGROUND: Patients with a small vessel diameter are independently associated with increased risk of adverse cardiac events after drug-eluting stent implantation. METHODS: A cohort of 265 patients treated with R-ZES (185 patients with 211 lesions) or PES (80 patients with 100 lesions) in small vessel (≤2.5 mm) lesions were retrospectively analyzed. The primary end point of the study was the composite of major adverse cardiac events. The secondary end points included target lesion revascularization (TLR), target vessel revascularization (TVR), and stent thrombosis at 3 years. RESULTS: The baseline characteristics were similar between the 2 groups. In the R-ZES group, the mean stent diameter was smaller and the total stent length per lesion was longer. Major adverse cardiac events occurred in 8 (10%) patients who had received PES and in 7 (3.8%) patients who had received R-ZES (P = .07). The rates of 3-year TLR (2.2% vs 2.5%; P = 1.00) and TVR (5.4% vs 10.0%; P = .17) showed no statistically significant difference between the R-ZES and PES groups. The rate of stent thrombosis was 0.5% in the R-ZES group and 2.5% in the PES group (P = .21). CONCLUSION: The rates of major adverse cardiac events and cardiac death were similar in the R-ZES-treated group compared with the PES-treated group.

Does Tight Glucose Control During the First 24 hours of Hospitalization Reduce Scintigraphic Infarct Size in STEMI Patients?

Abstract Background Hyperglycemia at the time of admission is related to increased mortality and poor prognosis in patients diagnosed with ST-segment elevation myocardial infarction (STEMI). Objective We aimed to investigate whether tight glucose control during the first 24 hours of STEMI decreases the scintigraphic infarct size. Methods The study population consisted of 56 out of 134 consecutive patients hospitalized with STEMI in a coronary care unit. Twenty-eight patients were treated with continuous insulin infusion during the first 24 hours of hospitalization, while the other 28 patients were treated with subcutaneous insulin on an as-needed basis. The final infarct size was evaluated with single-photon emission computed tomography (SPECT) in all patients on days 4 to 10 of hospitalization. The groups were compared and then predictors of final infarct size were analyzed with univariate and multivariate linear regression analysis. A p-value < 0.05 was considered statistically significant. Results The mean glucose level in the first 24 hours was 130 ± 20 mg/dL in the infusion group and 152 ± 31 mg/dL in the standard care group (p = 0.002), while the mean final infarct size was 20 ± 12% and 27 ± 15% (p = 0.06), respectively. The multivariate linear regression analysis demonstrated that the mean 24-hour glucose level was an independent predictor of the final infarct size (beta 0.29, p = 0.026). Conclusion Tight glucose control with continuous insulin infusion was not associated with smaller infarct size when compared to standard care in STEMI patients. (Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0)

Long-Term Follow-Up of Patients at High Risk for Nephropathy After Contrast Exposure.

Contrast medium-induced acute kidney injury (CI-AKI) is associated with morbidity and mortality, but the long-term outcomes of patients who do not develop CI-AKI remain unknown. We assessed clinical end points during long-term follow-up in patients at high risk for nephropathy who did not develop CI-AKI. Patients (n = 135) with impaired renal function (estimated glomerular filtration rate: 30-60 mL/min/1.73 m(2)) were divided into 2 groups according to contrast media (CM) exposure. The primary end point of this study was a composite outcome measure of death or renal failure requiring dialysis. Multivariate analyses identified CM exposure to be independently associated with major adverse long-term outcomes (hazard ratio: 2.3; 95% confidence interval, 1.34-6.52; P = .018). Even when CM exposure does not cause CI-AKI in patients with impaired renal function, in the long term, primary end points occur more frequently in patients exposed to CM than in those with no CM exposure.

Relationship between serum endothelin-1 level and spontaneous reperfusion in patients with acute myocardial infarction.

AIM: Spontaneous reperfusion (SR) was associated with better clinical outcomes and lower incidence of major adverse cardiovascular events. Endothelin-1 (ET-1) is a potent endothelium-derived vasoconstrictor peptide and elevated systemic ET-1 levels predict a poor prognosis in patients with ST-segment elevation myocardial infarction (STEMI). We aimed to investigate the relationship between systemic ET-1 plasma levels and SR in a group of STEMI patients treated with a primary percutaneous coronary intervention (PCI). METHODS AND RESULTS: We measured ET-1 levels acutely (within the first 6 h) in 33 STEMI patients with SR and 45 STEMI patients with non-SR presenting with their first STEMI who underwent primary PCI. Blood samples for ET-1 plasma level measurement were drawn after vascular puncture before angiography in the catheterization laboratory from the peripheral vein.The mean age of the patients was 56.1±13.3 years in the SR group and 57.4±11.4 years in the non-SR group. The circulating level of ET-1 was considerably higher in the non-SR patients than in the SR patients (0.81±0.2, 1.0±0.3, P=0.004). On multivariable logistic regression analysis, the ET-1 level was the only significant predictor of SR (P=0.01).The receiver operating characteristic curve analysis showed that the ET-1 level at admission is an indicator of SR, with an area under the curve of 0.62. CONCLUSION: This study shows that in patients admitted with ST-elevation acute myocardial infarction, ET-1 plasma levels are related to angiographic SR before primary PCI.

Admission hyperglycemia is associated with failed reperfusion following fibrinolytic therapy in patients with STEMI: results of a retrospective study.

BACKGROUND: Hyperglycemia on admission is associated with increased mortality rates in patients with ST-elevation myocardial infarction (STEMI) who are treated with either fibrinolytic therapy (FT) or primary percutaneous coronary intervention (PCI). However, data regarding the relationship between hyperglycemia and the success of FT are lacking. The aim of this study was to investigate the value of admission blood glucose for the prediction of failed reperfusion following FT. METHODS AND RESULTS: This is a retrospective study of 304 STEMI patients who received FT and whose admission glucose levels were recorded. The main outcome measure was ST segment resolution≥50%. The median (interquartile range [IQR]) blood glucose level in the entire study group was 112 (95-153). In 92 (30.2%) patients, FT was unsuccessful and rescue PCI was performed. Admission glucose (126 [99-192] vs. 110 [94-144] mg/dL, p<0.001), time from symptom onset to FT (180 [120-270] vs. 150 [120-180] min, p=0.009), and maximum ST elevation amplitude (3 [2-7] vs. 3 [2-6] mm, p=0.05) were higher in the failed reperfusion group than in the reperfusion group. Admission hyperglycemia was an independent predictive factor for failed reperfusion (hazard ratio 4.79 [1.80-12.76], p=0.002), along with time from symptom onset to fibrinolysis and anterior wall myocardial infarction. CONCLUSIONS: In patients with STEMI who undergo FT, admission hyperglycemia is an independent predictor of the failure of fibrinolysis.

Platelet-to-Lymphocyte Ratio Predicts Contrast-Induced Nephropathy in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome.

We assessed the relation between platelet-to-lymphocyte ratio (PLR) on admission and contrast-induced nephropathy (CIN) in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). A total of 488 patients with NSTE-ACS who underwent urgent coronary angiography were enrolled. Levels of PLR and creatinine were measured before angiography and at 72 hours after angiography. Patients were divided into 2 groups, namely, the CIN group, 80 patients (16.3%; age 65.3 ± 12.5years; 66.7% men) and the non-CIN group, 408 patients (83.7%; age 61.2 ± 12.3 years; 72.5% men). Patients in the CIN group had significantly higher PLR than those in the non-CIN group (152.9 ± 99.6 vs 120.4 ± 66.1, P < .001). In logistic regression analysis, PLR (odds ratio [OR] 1.004, 95% confidence interval [CI] 1.001-1.007, P = .02), diabetes mellitus (OR 1.75, 95% CI 1.02-2.98, P = .03), and ST-segment depression on admission electrocardiogram (OR 1.68, 95% CI 1.00-2.81, P = .04) were independent predictors of CIN. The PLR was an independent predictor of CIN after angiography in patients with NSTE-ACS.