Comparison of atrial fibrillation predictors in patients with acute coronary syndrome using ticagrelor or clopidogrel

Background/aim: Ticagrelor is a drug widely used in patients with acute coronary syndromes (ACS) that specifically increases the plasma level of adenosine, which is likely to cause atrial fibrillation (AF). Therefore, in this study we aimed to investigate the electrocardiographic and echocardiographic predictors of AF development after P2Y12 receptor antagonists in ACS patients. Materials and methods: This cross-sectional study included 831 patients with ACS (486 [58.5%] with ST elevated myocardial infarction [STEMI] and 345 [41.5%] with non-ST elevated myocardial infarction [NSTEMI]). Patients were divided into ticagrelor (n = 410) and clopidogrel (n = 421) groups. P wave properties including P wave dispersion and atrial electromechanical conduction properties were measured as AF predictors with surface ECG and tissue Doppler imaging. Results: Baseline characteristics such as age, sex, heart rate, blood pressure, and laboratory parameters were almost the same in the ticagrelor and clopidogrel groups. The statistical analysis showed no significant difference in P wave dispersion (PWD) between ticagrelor and clopidogrel groups (40.98 ± 12 ms versus 40.06 ± 12 ms, P = 0.304). Subgroups analysis according to ACS types also showed no significant difference in PWD (NSTEMI: 41.16 ± 13.8 ms versus 40.76 ± 13.55 ms, P = 0.799; STEMI: 40.9 ± 12.62 ms versus 39.19 ± 11.18 ms, P = 0.132). In addition, we did not find significant difference in atrial electromechanical delay (EMD) with tissue Doppler imaging (interatrial EMD 24.11 ± 3.06 ms versus 24.46 ± 3.23 ms, P = 0.279). Conclusion: In conclusion, we did not find any difference in detailed electrocardiographic and echocardiographic parameters as AF predictors between ticagrelor and clopidogrel groups in patients with ACS

The value of transient ischemic dilation for detecting restenosis after coronary artery revascularization.

AIM: Transient ischemic dilation (TID) is a marker of severe coronary artery disease (CAD). We aimed to assess the incremental value of TID in a cohort of patients with known significant CAD who had recurrence of symptoms after revascularization. METHODS: We identified in our databases 104 patients who had recent coronary revascularization and recurrence of symptoms. 62 patients had PCI (75 arteries) and 42 patients had CABG (104 arteries). All had follow-up stress SPECT MPI and repeat coronary angiography. Myocardial perfusion findings of ischemia and TID were correlated with presence of significant obstructive CAD (>70% stenosis). RESULTS: Follow-up stress Tc-99m Sestamibi SPECT MPI revealed inducible ischemia in 38 patients (36.5%) and TID > 1.20 in 49 patients (47%). Subsequent coronary angiography showed significant obstructive CAD in 44 patients (42%). The sensitivity for detecting obstructive CAD was 61% for SPECT MPI alone, but increased significantly to 93% by the addition of TID as a diagnostic criterion (P < 0.0001). CONCLUSIONS: In this selected patient cohort with prior coronary revascularization, TID is an important marker of obstructive CAD and has incremental value over SPECT MPI alone.

Inadvertent complication of prosthetic valve surgery: leaflet perforation.

There are various complications of prosthetic valvular surgeries. Among them, leaflet perforation should be emphasized and brought to mind when there have been eccentric valvular regurgitation. In this report, we presented 2 cases of iatrogenic aortic and mitral valve leaflet perforation after prosthetic valve surgeries.

The diagnosis and clinical importance of tumour neovascularisation from coronary artery to right atrial myxoma.

Myxomas are the commonest cardiac tumours and are usually localised in the atria. Neovascularisation in cardiac myxomas has been shown in previous case reports. However, the clinical importance of neovascularisation in cardiac myxomas is not well understood. In our case report, we present a right atrial myxoma in a 46 year-old woman admitted to our hospital with exertional angina and dyspnea. Coronary angiography revealed the presence of tumour neovascularisation from the right coronary artery, with no evidence of coronary artery stenosis. We thus speculate that neovascularisation of myxoma may cause typical anginal symptoms as a result of coronary steal phenomenon. Coronary angiography might help in the evaluation of the neovascularisation process and also in indicating surgery.

Cystic and hemorrhagic giant left atrial myxoma in a patient presenting with exertional angina and dyspnea.

Myxomas are the most common type of primary cardiac tumors and are usually localized in the atrium. The clinical features of the disease depend on the size, location, mobility, and fragility of the mass. In our case report, we present a 38-year-old female patient admitted to our hospital with typical exertional angina and dyspnea. Diagnosis of giant cystic/hemorrhagic atrial myxoma was established after imaging modalities including echocardiography, angiography, and radiology and the pathological evaluation of the mass. On the coronary angiography, a significant feeding artery of the tumor originating from the right coronary artery and the cystic/hemorrhagic appearance all raised the suspicion for the presence of other cardiac masses. However, the pathological evaluation of the mass was reported as consistent with myxoma, with many prominent cystic and hemorrhagic fields and no evidence of malignancy. Since large intratumoral hemorrhagic fields and the presence of a significant feeding artery secondary to tumor neovascularization were observed, we hypothesized that the remarkable amount of blood flow from the coronary artery to the giant myxoma may result in a kind of coronary steal phenomenon and typical anginal symptoms of the patient.

Prevention of contrast-induced impairment of renal function by short-term or long-term statin therapy in patients undergoing elective coronary angiography.

A decline in kidney function after contrast exposure is associated with a high risk of morbidity and mortality during hospitalization and over long-term periods. Several retrospective and recent prospective clinical trials have shown that statin therapy might prevent contrast-induced nephropathy in patients undergoing percutaneous coronary intervention. In this study, we aimed to assess the effects of statin therapies on renal function parameters in patients undergoing elective coronary angiography. One hundred and sixty patients undergoing elective coronary angiography were randomized equally into two groups: atorvastatin 40 mg/day group (statin started 3 days before coronary angiography) and an untreated control group. An additional 80 patients were included as a chronic statin therapy group. Serum creatinine, serum cystatin C, and glomerular filtration rate (GFR) were measured before and 48 h after coronary angiography. Cockcroft-Gault and Modification of Diet in Renal Disease (MDRD) equations were used to determine GFR. After coronary angiography, serum creatinine and GFR determined by MDRD were significantly better in patients using atorvastatin than those in controls (P = 0.002 and P = 0.004, respectively). Postprocedure serum creatinine, cystatin C, and GFR determined by MDRD were also significantly better in chronic statin therapy group than those in controls (P = 0.006, P = 0.003, and P = 0.004, respectively). There were no differences in renal function parameters between the short-term atorvastatin group and the chronic statin therapy group. Our data demonstrate that the use of short-term atorvastatin and chronic statin therapy may have a role in protecting renal function after elective coronary angiography.

Paraoxonase activity might be predictive of the severity of aortic valve stenosis.

BACKGROUND AND AIM OF THE STUDY: Aortic valve stenosis (AS) is the most common valvular heart disease in the western world, and in adults is invariably caused by the calcification of a normal tricuspid or congenital bicuspid valve. Calcific AS, as an active disease process, is characterized by lipid accumulation, inflammation and calcification that mimic atherosclerosis. Paraoxonase-1 (PON-1) is a high-density lipoprotein (HDL)-bound enzyme that exerts antiatherogenic properties by protecting low-density lipoprotein (LDL)-cholesterol from oxidative modification. The study aim was to examine the association between PON-1 activity and AS. METHODS: A total of 93 patients with angiographically normal coronary arteries was enrolled into the study. Transthoracic echocardiography was used to diagnose and grade the AS before the patients underwent selective coronary angiography. The patients were allocated to three groups of mild AS (n = 34), moderate AS (n = 31) and severe AS (n = 28). Paraoxonase activity was measured using a spectrophotometric technique. RESULTS: The mean PON-1 activity in patients with severe AS (64.4 +/- 29.8 U/l) was significantly lower than that in patients with mild and moderate AS (97.1 +/- 72.6 and 146.8 +/- 133.9 U/l; p = 0.03 and p = 0.002, respectively). Typically, PON-1 activity tended to be lower in moderate AS than in mild AS (p = 0.07). The serum PON-1 activity correlated positively with the aortic valve area, but negatively with the aortic mean and maximum gradients. CONCLUSION: The study results showed that PON-1 activity is lower in patients with calcific AS. In addition, PON-1 activity was inversely correlated with the severity of AS.

Patent foramen ovale among patients with mild chronic obstructive pulmonary disease and unexplained hypoxia.

PURPOSE: To evaluate whether patent foramen ovale (PFO) is a contributing factor to hypoxia in patients with chronic obstructive pulmonary disease (COPD). METHODS: Twenty-one patients over 40 years of age with mild COPD (Forced expiratory volume (FEV1)/Forced Vital Capacity (FVC): > 50%) who had hypoxia (PO(2) < 80 mmHg, SaO(2) < 95%) that could not be explained by COPD alone were included in this study. Arterial oxygen pressures (PO(2)) and arterial oxygen saturations (SaO(2)) were recorded from laboratory evaluations of arterial blood gases. Respiratory function tests were performed to analyze the degree of COPD. Standard and contrast echocardiography was used to calculate pulmonary artery pressure (PAP) levels and to determine patients with a PFO. RESULTS: The mean age of the patients was 64 +/- 12 years. Four patients (19%) had a PFO. The mean PO(2), mean SaO(2), and mean PAP levels were 57.4 +/- 6.8 mmHg, 90 +/- 3.2%, and 33.8 +/- 5.4 mmHg, respectively, in patients without PFO. The mean PO(2), mean SaO(2), and mean PAP levels were 46.5 +/- 13.7 mmHg, 79.3 +/- 12.8%, and 42.5 +/- 6.5 mmHg, respectively, in patients with PFO. There were no statistically significant differences noted between the two groups in the PO(2) levels (P = 0.172) and SaO(2) levels (P = 0.065). A comparison of the PAP levels revealed a statistically significant difference between the two groups, with values that were more elevated in the PFO group than in the non-PFO group (P = 0.031). CONCLUSION: This study demonstrated that PFO is not a contributing factor to deep hypoxia in COPD patients with lower PO(2) and SaO(2) levels; however, higher PAP levels were detected in patients with a PFO. Further studies involving a larger number of patients are needed to be conclusive.

Association between paraoxonase activity and late saphenous vein graft occlusion in patients with coronary artery bypass grafting.

BACKGROUND: Coronary vein graft disease is an important contributor to the morbidity after coronary artery bypass grafting (CABG). Late occlusion of the graft is a serious complication that limits the use of the saphenous vein as a coronary bypass conduit. It is frequently encountered in old, degenerated vein grafts with advanced atherosclerotic plaque formation. Paraoxonase-1 (PON-1) is an HDL-bound enzyme which has anti-atherogenic properties and protects LDL cholesterol from oxidative modification. AIM: To examine the association between PON-1 activity and late saphenous vein graft occlusion. METHODS: Thirty-eight patients who had at least one occluded saphenous vein graft (group 1; 12 females, 26 males) and 41 patients who had a patent saphenous vein graft (group 2; 7 females, 34 males) were enrolled in this study. Paraoxonase activity was measured spectrophotometrically. RESULTS: The mean PON-1 activity in group 1 was significantly lower than in group 2 (74.1 +/- 52.1 vs. 114.4 +/- 90.9 U/l, p = 0.02). The mean platelet volume was significantly higher in group 1 than group 2 (8.8 +/- 1.6 vs. 8.2 +/- 1.1 fl, p = 0.04). Multiple logistic regression analysis showed that only PON-1 activity (beta = 0.011, p = 0.042) was an independent predictor of late occlusion of a saphenous vein graft. CONCLUSIONS: Our results show that PON-1 activity is lower in patients with late saphenous vein graft occlusion. Reduced PON-1 activity may lead to acceleration of saphenous vein graft occlusion.

Multisided cardiac hemangiomas mimicking biatrial thrombus: atypically located cardiac hemangiomas of left atrial appendage and right atrium.

Hemangiomas are rare benign tumors of the heart. Clinical presentation is highly variable according to the location, size, and extension of the tumor. Hemangiomas have been described in all cardiac chambers, but most occur on the right side of the heart and in the left atrium. Although diagnosis is typically made by echocardiography, the definite diagnosis can be made with certainty only from a very careful histopathologic examination. The authors report a case of atypically located hemangiomas originating from the left atrial appendage and right atrium in a 71-year-old woman who presented with ischemic stroke. Transthoracic and transesophageal echocardiography demonstrated an elongated left atrial mass originating in the atrial appendage and extending well into the left atrium to the mitral orifice, as well as a right atrial mass and intense biatrial spontaneous echo contrast. It was unclear whether the masses represented thrombus or an unusually located atrial tumor. Immunohistologic examinations revealed a biatrial cavernous hemangioma with no signs of malignancy.

Right ventricular contractile reserve in mitral stenosis: implications on hemodynamic burden and clinical outcome.

BACKGROUND: We investigated whether isovolumic acceleration (IVA) under inotropic stimulation as a means of right ventricular (RV) contractile reserve, is a surrogate for hemodynamic burden and has prognostic value in patients with mitral stenosis (MS). METHODS: Thirty-one pure MS patients and 20 controls underwent cardiac catheterization, exercise test, and dobutamine stress echocardiography. RV fractional area change (FAC), +dP/dt/P(max), RV tissue Doppler indices (isovolumic contraction [IVC] and systolic [S] velocity, and IVA) were measured. Patients were followed-up for the occurrence of cardiac adverse events. RESULTS: Inotropic modulation unmasked statistically significant differences regarding magnitude of changes in IVA, IVC, S, and +dP/dt/P(max), but not RV FAC. Inability to increase IVA more than 6.5 m/s(2) was the only independent determinant of pulmonary capillary wedge pressure >or=18 mm Hg (P=.004). Although MS severity did not predict the RV contractile reserve and pulmonary artery pressure (PAP) behavior during inotropic stimulation, the RV contractile reserve was related to the degree of systolic PAP. IVA increases of <3.4 m/s(2) had 86% sensitivity and 75% specificity to predict unfavorable outcomes during long-term follow-up (20+/-8 months). CONCLUSION: RV contractile reserve provides complementary data to the hemodynamic significance of MS severity, may contribute to clinical decision making, and be of prognostic value in these patients.

Comparison of the efficacy of metoprolol and carvedilol for preventing atrial fibrillation after coronary bypass surgery.

BACKGROUND: Atrial fibrillation (AF) occurs frequently after coronary artery bypass grafting (CABG) and often results in prolonged postsurgical hospital stays and increased mortality and morbidity. Beta blockers are known to prevent postoperative AF. In this prospective study, we investigated the efficacy of carvedilol compared with metoprolol succinate in preventing postoperative AF. METHODS: Subjects included 110 patients (31 women, 79 men; mean age, 60+/-10 years, range, 39-82 years) who had undergone CABG. Patients were randomized to receive either metoprolol or carvedilol, and all patients received the drugs 3 days prior to surgery. Metoprolol was started at 50 mg twice daily and carvedilol was started at 12.5 mg twice daily. The doses were titrated according to the patients' hemodynamic responses. All patients were monitored for 3 days after the surgery. RESULTS: Of the 110 patients, 55 (50%) were treated with metoprolol succinate, and 55 (50%) were treated with carvedilol. Baseline characteristics and operative data of the patients did not differ between groups. During follow-up, 20 patients (36%) in the metoprolol group and 9 patients (16%) in the carvedilol group developed AF (P=0.029). Multiple stepwise logistic regression analysis showed that metoprolol use, older age, and impaired left ventricular ejection fraction were independent risk factors for developing AF, and carvedilol use was found to be independently related to sinus rhythm maintenance after CABG (P=0.02). CONCLUSIONS: These results show that carvedilol is superior to metoprolol in decreasing development of early postoperative AF.