In-stent restenosis estimation following carotid artery stenting: The robust predictive value of atherogenic index of plasma and other non-traditional lipid profiles.

OBJECTIVE: Atherosclerotic carotid artery stenosis is a significant contributor to ischemic strokes, and carotid artery stenting (CAS) has emerged as a pivotal treatment option. However, in-stent restenosis (ISR) remains a concern, impacting the long-term patency of CAS. This study aimed to investigate the predictive value of non-traditional lipid profiles, including the atherogenic index of plasma (AIP), in ISR development. METHODS: This retrospective single-center study involved patients presenting at a tertiary healthcare facility with severe carotid artery disease between 2016 and 2020 who subsequently underwent CAS. A total of 719 patients were included in the study. The study cohort was divided into ISR and non-ISR groups based on restenosis presence, confirmed by angiography following ultrasonographic follow-up assessments. Non-traditional lipid indices, such as AIP, atherogenic index (AI), and lipoprotein combined index (LCI), were evaluated along with traditional risk factors. RESULTS: During a 24-month follow-up, ISR occurred in 4.03% of patients. To determine the predictors of restenosis, three different models were constructed in multivariate analysis for non-traditional lipid indices. Multivariate analysis revealed AIP as a robust independent predictor of ISR (OR: 4.83 (CI 95 % 3.05-6.63, p < .001). Notably, AIP demonstrated superior predictive accuracy compared to AI and LCI, with a higher Area Under the Curve (AUC) of 0.971. CONCLUSION: Non-traditional lipid profiles, especially AIP, were found to be associated with an increased risk of ISR and may serve as predictors of ISR in patients undergoing CAS.

Relationship between P wave peak time and coronary artery disease severity in non-ST elevation acute coronary syndrome.

BACKGROUND: Early diagnosis of non-ST elevation acute coronary syndrome (NSTE-ACS) and prediction of the severity of current coronary artery disease (CAD) play a major role in patient prognosis. Electrocardiography has a unique value in the diagnosis and provides prognostic information on patients with NSTE-ACS. In the present study, we aimed to examine the relationship between P wave peak time (PWPT) and the severity of CAD in patients with NSTE-ACS. METHODS: A total of 132 consecutive patients (female: 35.6%; mean age: 60.1 ± 11.6 years) who were diagnosed with NSTE-ACS were evaluated retrospectively. Gensini scores (GSs) were used to define the angiographic characteristics of the coronary atherosclerotic lesions. The patients were divided into two groups according to the GS. The PWPT was defined as the duration between the beginning and the peak of the P wave, and R wave peak time (RWPT) was defined as the duration between the beginning of the QRS complex and the peak of the R wave. RESULTS: There were 59 (44.6%) patients in the high-GS group (GS ≥25 ) and 73 (55.3%) patients in the low-GS group (GS <25 ). Presence of diabetes mellitus, low left ventricular ejection fraction, and high RWPT and PWPT were identified as predictors of a high GS in the study population. There was no significant difference between the area under the curves of PWPT and RWPT for predicting the severity of CAD (0.663 vs. 0.623, respectively; p = 0.573). CONCLUSION: The present study found that both PWPT and RWPT on admission electrocardiography were associated with the severity and complexity of CAD in patients with NSTE-ACS.

The TAPSE/PASP ratio and MELD score in patients with advanced heart failure.

INTRODUCTION: The aim of this study was to explore the relationship between the tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure (TAPSE/PASP) ratio and model for end-stage liver disease (MELD) score in patients with advanced heart failure. METHODS: A total of 103 patients with advanced heart failure evaluated for candidacy for heart transplantation were included in this study. TAPSE was measured by M­mode echocardiography and cardiac catheterization was performed. TAPSE/ PASP ratio and MELD score were calculated. RESULTS: The median age of patients was 49 (40.5-54) years and the majority were male (92%). The percentage of patients with ischemic cardiomyopathy was 40%. The mean value of the group's MELD score was 10 ± 3.3 and the median value of TAPSE/PASP 0.24 (0.18-0.34). There was a moderate negative correlation between TAPSE/PASP and MELD score (r: -0.38, p < 0.001). Right atrial pressure (RAP) and left ventricular end-diastolic pressure (LVEDP) were also negatively correlated with TAPSE/PASP (correlation coefficients were r: -0.562 and r: -0.575, respectively). In patients with a lower TAPSE/PASP ratio, MELD score, LVEDP and RAP were higher and tricuspid regurgitation was more severe, but there were no significant differences between cardiac output (CO) and mean aortic pressure (mean BP). The presence of ischemia was found to be an independent predictor for lower values of TAPSE/PASP. CONCLUSION: The lower TAPSE/PASP obtained on echocardiography may be a sign of the multi-organ failure defined as a high MELD score in patients with advanced heart failure.

Evaluation of subvalvular pannus formation in mechanical aortic valve by transesophageal echocardiography.

Subvalvular pannus formation is a rare but clinically important complication with prosthetic valves. Transthoracic echocardiography still plays a role in the initial assessment of mechanical aortic valve dysfunction. But evaluation with transesophageal echocardiography is more useful. Subvalvular area may be a blind spot of echocardiography due to acoustic shadowing. The case presented herein underlines the significant role of transgastric plane and three-dimensional TEE in the assessment of subvalvular pannus formation in mechanical aortic valves.

Mitral-aortic intervalvular fibrosa pseudoaneurysm causing compression of superior vena cava and right atrium.

The mitral-aortic intervalvular fibrosa (MAIVF) is a fibrous, avascular region between the anterior leaflet of the mitral valve and noncoronary cusp of the aortic valve. This makes MAIVF vulnerable to injury and infection; thus pseudoaneurysm may develop. The pseudoaneurysm can cause compression to coronary arteries which causes angina or pulmonary artery resulting in pulmonary hypertension. We presented the pseudoaneurysm of MAIVF causing compression of superior vena cava and right atrium which was visualized by two- and three-dimensional transesophageal echocardiography and cardiac computed tomography.

Comparison of 30-Day MACE between Immediate versus Staged Complete Revascularization in Acute Myocardial Infarction with Multivessel Disease, and the Effect of Coronary Lesion Complexity.

Background and objective: In patients with acute myocardial infarction and multivessel disease, the timing of intervention to non-culprit lesions is still a matter of debate, especially in patients without shock. This study aimed to compare the effect of multivessel intervention, performed at index percutaneous coronary intervention (PCI) (MVI-I) or index hospitalization (MVI-S), on the 30-day results of acute myocardial infarction (AMI), and to investigate the effect of coronary lesion complexity assessed by the Syntax (Sx) score on the timing of multivessel intervention. Materials and methods: We enrolled 180 patients with MVI-I, and 425 patients with MVI-S. The major adverse cardiovascular events (MACE) for this study were identified as mortality, nonfatal myocardial infarction, nonfatal stroke, acute heart failure, ischemia driven revascularization, major bleeding, and acute renal failure developed within 30 days. Results: The unadjusted MACE rates at 30 days were 11.2% and 5% among those who underwent MVI-I and MVI-S, respectively (OR 3.02; 95% confidence interval (CI) 1.51⁻6.02; p=0.002). Associations were statistically significant after adjusting for covariates in the penalized multivariable model (adjusted OR 2.06; 95%CI 1.02⁻4.18; p=0.043), propensity score adjusted multivariable model (adjusted OR 2.46; 95%CI 1.19⁻5.07; p=0.015), and IPW (adjusted OR 2.11; 95%CI 1.28⁻3.47; p=0.041). We found that the Syntax score of lesions did not affect the results. Conclusion: MVI-S was associated with a lower incidence of major adverse cardiovascular events within 30 days after discharge.

Multidisciplinary Approach to Right Ventricular Myxoma.

Right ventricular (RV) myxoma that obstructs the RV outflow tract is rare. Multimodality imaging is crucial due to the curved and triangular shape of the RV anatomy. Incomplete resection by the right atrial approach in cardiac myxomas may be prevented by preoperative imaging with echocardiography, computed tomography and magnetic resonance imaging to provide detailed visualization. Right ventriculotomy may be an alternative approach to the isolated atrial approach to get complete resection of RV myxoma in suitable patients. The preferred surgical treatment is not well defined for ventricular myxomas and careful preoperative planning is essential. Surgical resection should be performed as soon as possible to avoid outflow tract obstruction, which might result in sudden death. The collaboration between cardiologist and heart surgeon and the effective use of imaging tools are essential for successful treatment. In this article, diagnosis and treatment and the heart team approach to RV myxoma are discussed with a demonstrative patient.

The relationship between H2FPEF and SYNTAX scores in patients with non-ST elevation myocardial infarction.

BACKGROUND: The Synergy between Percutaneous Coronary Intervention (SYNTAX) score, has been used to estimate the extent and complexity of coronary artery disease (CAD). The H2FPEF score enables robust discrimination of heart failure with preserved ejection fraction (HFpEF) from non-cardiac aetiologies of dyspnea. In the present study, we aimed to investigate the relationship between H2FPEF and SYNTAX scores in patients with non-ST elevation myocardial infarction (NSTEMI). METHOD: Two hundred eighty two consecutive patients with NSTEMI who underwent coronary angiographic examination were enrolled in this study. The H2FPEF score was calculated for each patient on admission. All patients underwent coronary angiography within 2 days following their admission. The SYNTAX scoring system was used to evaluate the severity and extent of CAD. RESULTS: The mean H2FPEF Score [3(2-4) vs 1(0.5-1.5), p < .001] and the frequencies of diabetes mellitus, hypertension and, atrial fibrillation were significantly higher and LVEF was significantly lower in patients with high SYNTAX score. High H2FPEF Score (OR: 3.61, 95%CI: 2.64-4.93; p = .001) and low left ventricular ejection fraction (OR: 0.94, 95%CI: 0.89-0.98; p = .013) were found to be independent associates for high SYNTAX score. H2FPEF Score above a cut-off level of 2.5 predicted high SYNTAX score with a sensitivity of 80% and a specificity of 82.5% (AUC: 0.890; 95%CI: 0.848-0.931; p < .001). There was a significant and moderate positive correlation between H2FPEF and SYNTAX Scores (r = 0.694, p < .001). CONCLUSION: High H2FPEF score may be associated with high SYNTAX score and may be used to estimate the extent and complexity of CAD in NSTEMI patients.

Association of C-Reactive Protein-to-Albumin Ratio With the Presence and Progression of Abdominal Aortic Aneurysm.

Aortic dilatation due to inflammation may lead to an increase in C-reactive protein (CRP) levels. We investigated the possible relationship between CRP-to-albumin ratio (CAR) and presence and progression of abdominal aortic aneurysms (AAAs). The study included 150 patients previously diagnosed with AAA (diameter 40-54 mm) and 100 normal controls. Clinical and laboratory parameters and maximal cross-sectional AAA diameters (measured by computed tomography angiography) were obtained from all participants at baseline assessment as well as after 1 year for those with an AAA. The patients with AAA had significantly higher serum CAR compared with controls at baseline (P < .001). Increased serum CAR was found to be an independent predictor of the presence of AAA (odds ratio: 3.162, 95% CI: 1.690-5.126, P = .001) after multivariate logistic regression analysis. There was a significant increase in aortic diameter and CAR after 1 year in the patients with AAA (P < .001; P = .003); a significant correlation was found between changes in the diameter of AAAs and CAR (r = 0.414; P = .005). Serum CAR may be useful as an inflammatory biomarker for the presence and progression of AAA.

Anxiety Disorder Associated with the COVID-19 Pandemic Causes Deterioration of Blood Pressure Control in Primary Hypertensive Patients.

OBJECTIVE: The new coronavirus disease (COVID-19) has spread rapidly all over the world and caused anxiety disorders. Recent studies have also shown that the prevalence of depression and anxiety increased during the COVID-19 outbreak. We aimed to evaluate the anxiety and depression levels during the pandemic and identify the effect of pandemic-related stress on blood pressure (BP) control in primary hypertensive patients. METHOD: A total of 142 patients with primary hypertension (HT) who continued to use the same antihypertensive drugs before and during the pandemic were included in the study. Twenty-four -hour Ambulatory Blood Pressure Monitoring (ABPM) and the Hospital Anxiety and Depression Scale (HADS) questionnaire were applied to patients. We retrospectively reviewed 24-h ABPM records of the same patients for the year before the pandemic. RESULTS: Daytime, nighttime and 24 -hour-systolic blood pressure (SBP) levels as well as daytime, nighttime, and 24- hour-diastolic blood pressure (DBP) levels , were significantly elevated during the COVID-19 outbreak compared to the pre-pandemic period (p<0.001). Higher HADS-A scores (HADS-A ≥7) were significantly associated with much greater increase in BP compared to the patients with lower HADS-A scores. CONCLUSION: Psychological stress due to the COVID-19 outbreak led to worsening of the regulation of BP in controlled hypertensive patients whose antihypertensive treatments did not change.

How does severe functional mitral regurgitation redefined by European guidelines affect pulmonary vascular resistance and hemodynamics in heart transplant candidates?

OBJECTIVE: Increased pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) are important prognostic factors in patients with heart transplantation (HT). It is well known that severe mitral regurgitation increases pulmonary pressures. However, the European Society of Cardiology and the 6th World Symposium of pulmonary hypertension (PH) task force redefined severe functional mitral regurgitation (FMR) and PH, respectively. We aimed to investigate the effect of severe FMR on PAP and PVR based on these major redefinitions in patients with HT. METHODS: A total of 212 patients with HT were divided into 2 groups: those with severe FMR (n=70) and without severe FMR (n=142). Severe FMR was defined as effective orifice regurgitation area ≥20 mm2 and regurgitation volume ≥30 mL where the mitral valve was morphologically normal. A mean PAP of >20 mm Hg was accepted as PH. Patients with left ventricular ejection fraction ≤25% were included in the study. RESULTS: The systolic PAP, mean PAP, and PVR were higher in patients with severe FMR than in those without severe FMR [58.5 (48.0-70.2) versus 45.0 (36.0-64.0), p<0.001; 38.0 (30.2-46.6) versus 31.0 (23.0-39.5), p=0.004; 4.0 (2.3-6.8) versus 2.6 (1.2-4.3), p=0.001, respectively]. Univariate analysis revealed that the severe FMR is a risk factor for PVR ≥3 and 5 WU [odds ratio (OR): 2.0, 95% confidence interval (CI): 1.1-3.6, p=0.009; and OR: 3.2, 95% CI: 1.5-6.7, p=0.002]. The multivariate regression analysis results revealed that presence of severe FMR is an independent risk factor for PVR ≥3 WU and presence of combined pre-post-capillary PH (OR: 2.23, 95% CI: 1.30-3.82, p=0.003 and OR: 2.30, 95% CI: 1.25-4.26, p=0.008). CONCLUSION: Even in the updated definition of FMR with a lower threshold, severe FMR is associated with higher PVR, systolic PAP, and mean PAP and appears to have an unfavorable effect on pulmonary hemodynamics in patients with HT.

The relationship between dual antiplatelet treatment (DAPT) score and saphenous venous grafts patency after coronary artery bypass grafting surgery.

BACKGROUND: Coronary artery bypass grafting (CABG) remains the gold standard treatment for mutivessel and left main coronary artery disease (CAD). Saphenous vein graft (SVG) patency is still a problem in CAD patients after CABG surgery. The Dual Antiplatelet Treatment (DAPT) score is a clinical prediction tool that predicts ischaemic and bleeding risk in CAD patients. The aim of this study is to investigate the relationship between DAPT score and SVG patency in CABG patients. METHOD: This retrospective study enrolled a total of 398 patients (68 female; mean age 65.8 ± 9.1 years) with a history of CABG surgery. The study population was divided into two subgroups according to SVG patency. The DAPT score was calculated for each patients and compared between the two groups. RESULTS: Coronary angiography revealed SVG disease in 212 patients and SVG patency in 186 patients. The rates of diabetes mellitus and hypertension, red cell distribution width values, DAPT Score, time interval after CABG and number of SVGs were significantly higher while LVEF was significantly lower in patients with SVG disease. The presence of diabetes mellitus, high DAPT score, long time interval after CABG and high number of SVGs were found to be independent predictors of SVG patency. DAPT score above 2.5 predicted SVG disease with a sensitivity of 77.1% and a specificity of 87.1% (AUC: 0.873; 95%CI: 0.823-0.924; p < 0.001). CONCLUSION: The DAPT score may provide useful information for SVG patency in CABG patients. Patients with high DAPT score should be followed up closely for SGV occlusion. DAPT score may be useful prior to CABG in determining the duration of dual anti-platelet therapy and in encouraging the use of arterial grafts with better patency.

Infrequent origin of a peripheral embolism: Arterial thoracic outlet syndrome in a young woman.

Arterial thoracic outlet syndrome (TOS) is caused by the compression of the subclavian or axillary artery between the ribs and the scalene muscles. Patients may present with various clinical conditions. Herein, we report a case of arterial TOS who presented with peripheral embolism. Arterial TOS is an uncommon cause of peripheral embolism. The diagnostic approach and treatment methods used are discussed. Clinicians should keep this diagnosis in mind and manage these cases according to the clinical appearance.

Serum lactate level may predict the development of acute kidney injury in acute decompensated heart failure.

OBJECTIVE: Acute decompensated heart failure (ADHF) is a life-threatening medical condition and more than 30% of patients hospitalized for ADHF develop acute kidney injury (AKI), which increases the rate of both mortality and morbidity. Previous research has indicated that several biomar- kers may help to predict the development of AKI. The aim of this study was to investigate the relationship between lactate level at the time of admission and AKI in ADHF patients. METHODS: A total of 154 consecutive ADHF patients were prospectively enrolled from June 2018 to December 2018, and after applying the exclusion criteria, a total of 91 patients were included in the study. The patients were divided into 2 groups: those with and without AKI. RESULTS: There were 63 patients in the group without AKI and 28 patients in the group with AKI. The AKI group had a higher percentage of a history of chronic kidney disease (CKD), a higher creatinine level, lower glomerular filtration rate level, lower bicarbonate level, higher lactate level, and a lower left ventricular ejection fraction compared with the non-AKI group (p<0.05 for all parameters). Multiple logistic regression analysis determined that CKD history (odds ratio [OR]: 4.003, 95% confidence interval [CI]: 1.295-12.371; p=0.016) and lactate level (OR: 1.545, 95% CI: 1.222-1.954; p<0.001) were independent predictive parameters for developing AKI. CONCLUSION: An elevated lactate level may help to make an early diagnosis of AKI, an important concern in ADHF.

Presence of ear lobe crease may predict intermediate and high-risk patients with acute non-ST elevation acute coronary syndrome.

Introduction: Ear lobe crease (ELC) was first described in 1973 as a physical examination finding indicating significant coronary artery disease (CAD). Several studies have been carried out in relation to this finding, and it has been shown that it is a marker of intima-media thickness, carotid artery disease, and CAD. We aimed to investigate the relationship between earlobe crease, which is a simple physical examination finding, and GRACE score as a risk estimation index in acute coronary syndromes without ST-segment elevation (NSTE-ACS) patients. Methods: 360 patients (mean age 62.2 years, 70% male) were included in our study. Patients were divided into two groups of GRACE scores ≤ 109 and >109, 167 patients were enrolled in group 1, and193 cases in group 2. Results: The group 2 patients were older, had higher systolic blood pressure (SBP) levels, a higher rate of hypertension, higher glucose levels, lower creatinine clearance levels, higher initial and peak troponin levels, lower hemoglobin levels, lower left ventricular ejection fraction (LVEF) and higher Gensini scores than the patients in group 1. The higher GRACE score group had markedly increased frequencies of ELC compared to the lower GRACE score group (80.8% vs. 24.5%, respectively, P < 0.001). Conclusion: The presence of ELC may predict moderate to high risk group of patients with NSTEACS.

Echocardiographic assessment of right ventricle free wall strain for prediction of right coronary artery proximal lesion in patients with inferior myocardial infarction.

In this study, our objective was to evaluate right ventricular functions with speckle-tracking and conventional echocardiographic methods in patients with acute inferior myocardial infarction and to investigate the correlation between the echocardiographic parameters and the prediction of the proximal RCA lesions. 77 patients were included in this study. Patients with a RCA occluded proximal to the right ventricular branch were assigned to Group 1 and patients with an RCA occlusion distal to the right ventricle branch were assigned to Group 2. All echocardiographic examinations were carried out within 24 h after PTCA, which was performed for the treatment of inferior myocardial infarction. RV TAPSE, RV TDI Sm, FAC, RV-FW strain, RV-FW SRE', RV-FW SRA' and RV E/Em which were statistically significant in univariate analysis were evaluated with the help of the multivariate logistic regression analysis. In the multivariate logistic regression test; RV-FW strain (OR 0.751, 95% CI 0.592-0.954, p = 0.019) and RV E/Em (OR 0.442, 95% CI 0.252-0.776, p = 0.004) were determined as the independent predictive parameters for proximal RCA occlusion. In the ROC analysis, RV-FW strain > - 14.75% predicted the proximal RCA occlusion with 83% sensitivity and 61% specificity (AUC = 0.81, p < 0.001) and RV E/Em > 6.25 with 68% sensitivity and 80% specificity (AUC = 0.79, p < 0.001). In this study, we demonstrated that decreased RV FW strain and increased RV E/Em were predictive parameters for the presence of the proximal RCA in patients with acute inferior MI.