Inappropriate shock and battery switching to "End of Life" in a patient with biventricular ICD during magnetic resonance imaging.

Presence of a cardiac pacemaker or implantable cardioverter defibrillator (ICD) is a relative contraindication to magnetic resonance imaging (MRI). Biventricular ICDs are often used in the treatment of advanced heart failure; however, reports on experience with biventricular ICDs are lacking in the literature. In this case report, we describe a pacemaker-dependent patient with a biventricular ICD on whom an MRI of the lumbar spine was performed without having realized the presence of the ICD.

The Effects of Niacin on Inflammation in Patients with Non-ST Elevated Acute Coronary Syndrome.

BACKGROUND: In this study, we aimed to evaluate the effects of niacin on high sensitivity C reactive protein (hs-CRP) and cholesterol levels in non-ST elevated acute coronary syndrome (NSTE-ACS) patients. METHODS: In this prospective, open label study, 48 NSTE-ACS were randomized to niacin or control group. Patients continued their optimal medical therapy in the control group. In the niacin group patients were assigned to receive extended-release niacin 500 mg/day. Patients were contacted 1 month later to assess compliance and side effects. Blood samples for hs-CRP were obtained upon admittance to the coronary care unit, in the third day and in the first month of the treatment. Fasting blood samples for cholesterol levels were obtained before and 30 days after the treatment. The primary end point of the study was to evaluate changes in hs-CRP, cholesterol levels, short-term cardiovascular events, and the safety of niacin in NSTE-ACS. RESULTS: Baseline demographic, clinical and laboratory characteristics were similar between the two groups. Logarithmic transformation of baseline and 3(rd) day hs-CRP levels were similar between the groups; but 1 month later, logarithmic transformation of hs-CRP level was significantly lower in the niacin group (0.43 ± 0.39 to 0.83 ± 0.91, p = 0.04). HDL-C level was significantly increased in the niacin group during follow-up. Drug related side effects were seen in 7 patients in the niacin group but no patients discontinued niacin. CONCLUSIONS: Our findings demonstrate that lower dose extended release niacin can be used safely and decreases hs-CRP and lipid parameters successfully in NSTE-ACS patients. KEY WORDS: Acute coronary syndrome; hs-CRP; Inflammation; Niacin.

Implantation of a cardiac resynchronization therapy-defibrillator device in a patient with persistent left superior vena cava.

Presence of a persistent left superior vena cava (PLSVC) is generally clinically asymptomatic and discovered incidentally during central venous catheterization. However, PLSVC may cause technical difficulties during cardiac device implantation. An 82-year-old man with heart failure symptoms and an ejection fraction (EF) of 20% was scheduled for resynchronization therapy-defibrillator device (CRT-D) implantation. A PLSVC draining via a dilated coronary sinus into an enlarged right atrium was diagnosed. First, an active-fixation right ventricular lead was inserted into the right atrium through the PLSVC. The stylet was preshaped to facilitate its passage to the right ventricular apex. An atrial lead was positioned on the right atrium free wall, and an over-the-wire coronary sinus lead deployed to a stable position. CRT-D implantation procedure was successfully completed.

A Case Report of Ventricular Fibrillation Survival by Left Ventricular Assist Device for Hours.

In recent years, the population of patients implanted with a left ventricular assist device has been increasing. Ventricular arrhythmias are the most interesting and most deadly complications among patients with these implants. Ventricular arrhythmias may cause cardiovascular collapse and death in some cases, whereas they may be asymptomatic or less symptomatic in others. In the case described here, we present the therapeutic approach to a patient with a left ventricular assist device who had ventricular fibrillation and the pathophysiology of his clinical condition.

Significant Improvement of Cardiac Dysfunction After Kidney Transplant: A Case Report.

Kidney transplant is known to reverse cardiac dysfunction in patients with end-stage renal disease, and low ejection fraction in kidney transplant candidates is considered to be a contraindication for transplant. We present a significant improvement in cardiac dysfunction after successful kidney transplant in a 21-year-old male recipient. Kidney transplant may be beneficial for cardiac function in transplant recipients who have impaired cardiac function prior to the procedure and caused by uremic toxins.

Left atrial mechanics for secondary prevention from embolic stroke of undetermined source.

AIMS: Anticoagulation is not justified unless atrial fibrillation (AF) is detected in cryptogenic stroke (CS) patients. We sought to explore whether left atrial (LA) remodelling is associated with embolic stroke of undetermined source (ESUS). METHODS AND RESULTS: In this prospective study, we evaluated consecutively 186 patients in sinus rhythm who presented with an acute ischaemic stroke (embolic and non-embolic) and sex- and age-matched controls. We performed continuous electrocardiogram (ECG) monitoring to capture paroxysmal AF episodes as recommended by the guidelines. After 12 months of follow-up, continuous ECG monitoring was repeated in patients with undetected AF episodes. We quantified LA reservoir and contraction strain (LASr and LASct) by speckle-tracking, LA volumes by 3D echocardiography. Out of 186 patients, 149 were enrolled after comprehensive investigation for the source of ischaemic stroke and divided into other cause (OC) (n = 52) and CS (n = 97) groups. CS patients were also subdivided into AF (n = 39) and ESUS (n = 58) groups. Among CS patients, LA strain predicted AF independently from CHARGE-AF score and LA volume indices. ESUS group, despite no captured AF, had significantly worse LA metrics than OC and control groups. AF group had the worst LA metrics. Moreover, LASr predicted both CS (embolic stroke with and without AF) and ESUS (embolic stroke with no detected AF) independently from LAVImax and CHA2DS2-VASc score. LASr >26% yielded 86% sensitivity, 92% specificity, 92% positive, and 86% negative predictive values for the identification of ESUS (areas under curve: 0.915, P < 0.0001, 95% confidence interval: 0.86-0.97). CONCLUSION: Echocardiographic quantification of LA remodelling has great potential for secondary prevention from ESUS.

[Serum gamma-glutamyltransferase activity: a new marker for coronary artery bypass graft disease]. / Serum gama-glutamiltransferaz aktivitesi: Koroner arter baypas greft hastaligi için yeni bir belirteç

OBJECTIVES: Serum gamma-glutamyltransferase (GGT) activity has been shown to be related to the development of atherosclerosis and cardiovascular events. We evaluated the association between GGT and severe graft disease in patients undergoing coronary artery bypass graft (CABG) surgery. STUDY DESIGN: We evaluated 113 patients (mean age 62±9 years; range 21 to 81 years) who underwent control coronary angiography after a mean of 39 months (range 18 to 84 months) following CABG surgery. A graft was considered patent if there was <70% stenosis or severely diseased if there was ≥70% stenosis on coronary angiography. Preoperative serum GGT levels were measured in all the patients and none had severe systemic or hepatobiliary disease. The association between serum GGT level and severe graft disease was investigated. The grafts were also evaluated separately. RESULTS: Coronary angiography showed severe graft disease involving at least one graft in 65 patients (57.5%). Serum GGT level was significantly higher in patients with severe graft disease (p=0.001). ROC curve analysis yielded a cut-off value of 29.5 U/l for serum GGT level to predict severe graft disease (area under the curve: 0.69) with 48% sensitivity and 82% specificity. While GGT levels were similar for internal mammary artery grafts (p>0.05), radial artery grafts and saphenous vein grafts (SVG) with severe graft disease were associated with significantly higher GGT levels (p=0.003 and p<0.001, respectively). In multivariate analysis, family history of coronary artery disease at a young age (OR 2.46, 95% CI 1.08-5.61, p=0.03) and serum GGT (OR 1.03, 95% CI 1.00-1.07, p=0.05) were independent predictors of severe graft disease. Separate analysis based on the graft types showed that GGT was an independent predictor of severe graft disease for only SVG (OR 1.02, 95% CI 1.00-1.04, p=0.03). CONCLUSION: Serum GGT level may be an independent marker for the development of severe SVG disease in patients undergoing CABG surgery.

Increased serum gamma-glutamyltransferase activity in patients with metabolic syndrome.

OBJECTIVES: Accumulating data indicate that serum gamma-glutamyltransferase (GGT) activity represents a true marker of atherosclerotic cardiovascular disease and has prognostic importance. In this study, we sought to evaluate serum GGT activity in patients with metabolic syndrome (MetS). STUDY DESIGN: We enrolled 232 patients (mean age 60.4 years) from our outpatient cardiology clinic, 117 with and 115 without MetS (control group) as defined by the ATP-III criteria. The results of serum liver function tests including serum GGT and C-reactive protein (CRP) levels were compared between the two groups. RESULTS: The two groups were similar with regard to age, sex, smoking, and family history of coronary artery disease (p>0.05). The prevalences of hypertension and dyslipidemia were significantly higher in patients with MetS. Compared with controls, patients with MetS had significantly higher serum GGT [(median 21, interquartile range (16-33) vs. 19 (14-26) U/l; p=0.008] and C-reactive protein levels [6.2 (3.6-9.4) vs. 5.0 (3.1-7.0) U/l; p=0.044]. A high GGT activity (>40 U/l) was determined in 14.5% of the patients with MetS and in 4.4% of the control subjects (p=0.012). Serum GGT level showed significant correlations with MetS (r=0.24, p=0.001), CRP (r=0.20, p=0.003), triglyceride (r=0.18, p=0.006), HDL cholesterol (r=-0.19, p=0.004), aspartate aminotransferase (r=0.15, p=0.02), alanine aminotransferase (r=0.32, p=0.001), and alkaline phosphatase (r=0.16, p=0.01). This significant association continued only for MetS (ß=-0.25, p=0.03), HDL cholesterol (ß=-0.18, p=0.03), and alkaline phosphatase (ß=0.17, p=0.01) in multivariate regression analysis. CONCLUSION: Our findings suggest that patients with MetS have higher serum GGT and CRP levels compared with controls. This increased GGT level might be a marker of increased oxidative stress and premature atherosclerosis.

Double Layer Reconstruction of Exposed Cardiac Implantable Electronic Devices in Elderly Patients.

Background Elderly patients with multiple comorbidities may not be candidates for cardiac implanted electronic device (CIED) explantation in cases of exposition. Excision of all unhealthy and inflamed scar tissue results in a skin defect that must be covered. Small- to moderate-sized local skin flaps and subpectoral placement of CIEDs have been described in the literature. However, these techniques still could not eliminate the risk of recurrence. In terms of minimizing the recurrence risk, we aim to increase the flap dimensions for getting better circulation and tension-free closure after subpectoral placement. Material and methods Six patients who were operated for a dual-layer reconstruction of exposed cardiac implants between 2017 and 2020 were included in the study. All patients were referred to plastic surgery as soon as the wound biopsy culture results were negative after systemic and topical antibiotic treatment by cardiology department. Results No flap loss or wound dehiscence was seen with a mean duration of 11 months follow-up. Early hematoma was encountered in a patient who was managed with irrigation and drain renewal. One patient developed suture abscess in the second month postoperatively. Knots were removed and wound healed without further intervention. Conclusion Double layer closure of exposed cardiac implants with large breast fasciocutaneous flap after subpectoral placement of pulse generator and leads suggest durable and reliable coverage in elderly patients with multiple comorbidities.

Glycoprotein IIIa gene polymorphism and coronary artery disease.

OBJECTIVE: Prevalence of glycoprotein IIIa gene polymorphisms (PIA2) has been reported to be elevated in persons who die of sudden death. PIA2 has been suggested as contributing to the development of atherosclerosis via coronary plaque rupture and thrombus formation. In this prospective study, we investigated the correlation between the PIA2 polymorphism, atherosclerotic plaque burden, and its prognostic significance. METHODS AND RESULTS: One hundred and seventy-eight patients (mean age 51 +/- 9.6 years) suspected to have atherosclerotic coronary artery disease underwent a coronary angiography and were evaluated for gene polymorphisms. Patients were followed up for 4 years for major adverse cardiac events (MACE). Thirty-eight patients (21%) had the PIA2 polymorphism.There was no statistically significant correlation between presence of atherosclerotic plaque burden, severity of coronary artery stenosis, and glycoprotein genotype. During the follow-up there were no significant differences between the 2 groups with regard to MACE. Any cause of death and cardiovascular death were higher in patients with PIA2 polymorphism but these differences were not significant. On univariate analysis, smoking, presence of severe coronary artery disease, and presence of myocardial infarction were correlated with elevated risk of MACE; presence of atypical angina was correlated with fewer MACE. On multivariate analysis, smoking was an independent risk factor for a MACE. On univariate or multivariate analysis, there was no relation between the PIA2 polymorphism and a MACE. CONCLUSIONS: The glycoprotein IIb/IIIa genotype was not shown to indicate the presence of atherosclerotic plaque. There was no correlation between the genotype and plaque vulnerability.

Risk factors for left atrial appendage thrombus.

Background: Atrial fibrillation (AF) is the most common persistent rhythm disorder that has been shown to be associated with a significant increase in stroke risk. Left atrial appendage (LAA) thrombi are responsible for most of strokes of cardiac origin. CHA2DS2-VASc is a risk scoring system to identify patients' indications for anticoagulation in nonvalvular AF patients. The aim of our study was to investigate CHA2DS2-VASc score, the other risk factors, echocardiographic data and blood parameters for LAA thrombus.Methods: Two hundred and sixty-four patients who were admitted to our adult cardiology outpatient clinic and who underwent a transesophageal echocardiography procedure between June 2017 and June 2019 included in our study. Patient's demographic data, transthoracic echocardiographic examinations, and laboratory results were recorded retrospectively.Results: LAA thrombus was detected in 39 (14.7%) patients. The rates of coronary artery disease and systolic dysfunction were significantly higher in patients with LAA thrombus (p = .017, p = .016, respectively). When AF subtypes were examined in detail, thrombus rate was significantly higher in persistent AF (51 vs. 25.7%, p = .002). Although the CHA2DS2-VASc score was slightly higher in the thrombus group, there was no statistically significant difference between the two groups (3.0 ± 1.65 vs. 2.78 ± 1.66).Conclusions: In conclusion, CHA2DS2-VASc score system itself was not informative about LAA thrombus formation although some of its components were related with LAA thrombus formation. According to a multiple regression analysis, the independent determinants of LAA thrombus were the presence of AF and coronary artery disease.

Epsilon-like electrocardiographic pattern in a patient with Brugada syndrome.

Both Brugada syndrome (BrS) and arrhythmogenic right ventricle dysplasia/cardiomyopathy (ARVD/C) can cause repolarization abnormalities in right precordial leads and predispose to sudden cardiac death (SCD) due to ventricular arrhythmias. Although there is controversy over whether BrS is distinct from ARVD/C, it is believed that both are different clinical entities with respect to both the clinical presentation and the genetic predisposition. The coexistence of these two relatively rare clinical entities is also reported, but, some hypothesized that it is more possible that disease of the right ventricular muscle might accentuate the Brugada electrocardiographic pattern. In clinic practice, there may be cases where the dividing line is not so clear. We report a 33-year-old male presenting with recurrent syncope, who has a peculiar pattern of coved-type ST-segment elevation (ST-SE) with epsilon-like wave in right precordial leads.

The effects of short time right ventricular pacing on left atrial mechanical functions.

OBJECTIVES: Left atrium (LA) plays an important role in left ventricular filling. It is well known that right ventricular apical pacing has unfavorable effects on ventricular systolic and diastolic performance. The aim of this study is to evaluate the LA mechanical functions with 2D echocardiography in patients with a permanent pacemaker after short time ventricular pacing. DESIGN: Echocardiographic examination was performed in 38 patients (mean age 63.0+/- 10.9, 18 female) with dual chamber pacemakers or defibrillators (< 20% ventricular pacing within previous 6 months, all of them on sinus rhythm) before and after 4 hours > 90% ventricular pacing at 70 beats per minute in DDD mode with an optimal AV interval. Left atrial volumes (LAV) including at the time of mitral valve opening (Vmax), at closure (Vmin), and at the onset of atrial systole (Volp) were measured. The passive emptying, conduit, active emptying and total emptying volume, stroke volumes were also calculated. RESULTS: No significant differences were noted at baseline and after pacing for absolute Vmax, Volp, passive emptying, conduit, active emptying, total emptying volumes as well as the volumes indexed to body surface area (p >0.05). CONCLUSIONS: Short - time RV pacing seems to have no acute effects on left atrial mechanical functions.

A case of myotonic dystrophy presenting with ventricular tachycardia and atrial fibrillation.

Myotonic dystrophy type 1 (MD1) is an autosomal dominant disorder characterized by myotonia, progressive muscular weakness, cataract, and cardiac involvement. Cardiac involvement is common and includes conduction system abnormalities, supraventricular and ventricular arrhythmias, and less frequently, myocardial dysfunction and ischemic heart disease. A 54-year-old woman with a previous diagnosis of MD1 was admitted with palpitation, blood pressure of 157/118 mmHg, and a heart rate of 220 beats/min. Electrocardiography (ECG) showed ventricular tachycardia. Within minutes, hemodynamic collapse developed and electrical cardioversion was performed. Immediately following cardioversion, ECG showed atrial fibrillation, a slightly prolonged QT interval, and intraventricular conduction delay. After intravenous infusion of amiodarone, the rhythm converted to sinus. Transthoracic echocardiography showed significantly depressed left ventricular function, an ejection fraction of 25%, and normal coronary arteries. During electrophysiological study, atrium-His interval and His-ventricle interval were 120 msec was 54 msec, respectively, and monomorphic ventricular flutter was induced. An implantable cardioverter-defibrillator was placed. She was discharged in sinus rhythm.

Tissue Doppler evaluation of the effects of major lung resection on cardiac functions.

OBJECTIVES: The aim of our study was to evaluate the influence of lung resection on cardiac functions by using tissue Doppler echocardiography. STUDY DESIGN: Nineteen consecutive patients (15 males, 4 females; mean age 55+/-8 years) undergoing major lung surgery (16 lobectomy, 3 pneumonectomy) were evaluated in a prospective design. Malignant lung cancer (n=15, 79%) was the major cause for lung surgery. Exclusion criteria were a history of myocardial infarction, angina, atrial fibrillation, valvular heart disease, major arrhythmias, diastolic dysfunction, heart surgery, and FEV1/FVC ratio lower than 60%. Two-dimensional Doppler echocardiography and tissue Doppler imaging (TDI) were performed one or two days before surgery and 4+/-2 weeks postoperatively. RESULTS: Compared to the preoperative measurements, right and left atrial and ventricular dimensions did not differ after surgery (p>0.05). Left ventricular ejection fraction, left ventricular end-systolic and end-diastolic volumes were preserved postoperatively. The following Doppler parameters showed significant changes after surgery: mitral A wave (92+/-23 cm/sec vs. 105+/-27 cm/sec, p=0.005), mitral E/A ratio (1.0+/-0.2 vs. 0.8+/-0.2, p=0.001), tricuspid A wave (65+/-19 cm/sec vs. 80+/-30 cm/sec, p=0.006), and tricuspid E deceleration time (327+/-68 msec vs. 274+/-51 msec, p=0.01). Concerning TDI parameters, there were significant differences in mitral E'/A' ratio (1.0+/-0.4 vs. 0.8+/-0.3, p=0.03) and tricuspid E' wave (9+/-2 cm/sec vs. 8+/-3 cm/sec, p=0.03) after surgery. CONCLUSION: Findings of our study suggest that systolic functions are preserved but diastolic functions are affected after major lung resection in a relatively short time period.

The Novel CHA2DS2-VASC-FSH Score is Predictive of Severe Coronary Artery Disease on Coronary Angiography in Patients with Atrial Fibrillation and Unstable Symptoms.

OBJECTIVE: AF may create confusion about the presence of severe or unstable coronary artery disease in cases with unstable symptoms. Novel scores and markers are needed to determine severe coronary artery disease in such patients. We aimed to test the newly developed CHA2DS2-VASc-FSH score, developed by adding family history for coronary artery disease, hyperlipidemia, and smoking to the original CHA2DS2-VASc score, in the prediction of severe CAD in patients with AF and unstable symptoms. MATERIALS AND METHODS: We retrospectively analyzed 72 patients presenting to Baskent Universtiy School of Medicine Hospital between April 2011 and January 2016. The CHA2DS2VASc-FSH score was assessed for the prediction of severe CAD. RESULTS: Seventy-two patients aged 65.7±11.2 years were enrolled. Thirty-five (48.6%) patients had severe CAD and 11 (15.3%) had unstable CAD. patients with severe coronary artery disease had a significantly greater CHA2DS2VASC-FSH score (5 (1-8) vs 3(0-7); p<0.05). The CHA2DS2VASC-FSH score independently predicted severe CAD, with a CHA2DS2VASc-FSH score of 3 or greater having a sensitivity of 77.1% and a specificity of 56.8% for severe CAD. CONCLUSION: Among patients with AF and unstable symptoms, the CHA2DS2VASc-FSH score independently predicts severe CAD.

Natriuretic Peptides in Clinical Practice.

Natriuretic peptides have long been introduced into clinical practice. These biomarkers have certainly been shown to provide useful information in the diagnosis, prognosis and risk stratification in heart failure and also may have a role in the guidance of heart failure therapy. Although, there are some limitations in using of these markers such as lack of specificity, aging, renal dysfunction or obesity, among the huge number of candidates for heart failure biomarkers, only natriuretic peptides are currently widely used in daily clinical practice in heart failure. Recent heart failure guidelines recognize natriuretic peptides as an essential tool in the new diagnostic and therapeutic algorithms. Furthermore, natriuretic peptides are not only used in the diagnosis or prognosis of heart failure, but also these biomarkers are referred to have some potential role in primary prevention, cardio-oncology, advanced heart failure, assessment of response to cardiac resynchronization therapy, pulmonary arterial hypertension, acute coronary syndromes, atrial fibrillation and valvular heart disease. In this article, natriuretic peptides have been reviewed for their updated information and new recommendations in heart failure and also potential role of these biomarkers in the management of various clinical conditions have been addressed in the form of expert opinion based on the available data in the literature.

Effect of mechanical dyssynchrony and cardiac resynchronization therapy on left ventricular rotational mechanics.

Alterations in rotational mechanics can bring new aspects to the understanding of left ventricular (LV) dyssynchrony. The aims of this study were to investigate LV rotational mechanics in candidates for cardiac resynchronization therapy (CRT) and to assess the effect of CRT by speckle-tracking echocardiography. Fifty-four patients with heart failure and 33 healthy controls were studied. Thirty-three underwent CRT. Speckle tracking was applied to short- and long-axis views. Radial and longitudinal dyssynchrony were assessed as previously defined. Apical and basal rotations were measured as the average angular displacement about the LV central axis. LV twist and torsion were then calculated. Peak apical and basal rotation, peak LV twist and torsion, apical and basal rotation at aortic valve closure (AVC), and LV twist and torsion at AVC were significantly lower in patients than controls. Apical-basal rotation delay and AVC-to-peak LV twist interval were longer in patients and associated with decreased peak LV twist and LV twist at AVC, respectively. In patients, rotational indexes, particularly LV twist and torsion, were correlated strongly with radial dyssynchrony. LV torsion (cutoff 0.1 degrees /cm) and twist (cutoff 1 degrees ) at AVC had the highest sensitivity (90%) and specificity (77%) to predict CRT responders among all other parameters, including radial and longitudinal dyssynchrony. In conclusion, LV dyssynchrony is associated with discoordinate rotation of the apical and basal regions, which in turn significantly decreases peak LV twist and torsion and LV twist and torsion at AVC. CRT significantly restored the altered rotational mechanics in responders. These parameters have potential for predicting responders to CRT.

Serum gamma-glutamyl transferase activity: new high-risk criteria in acute coronary syndrome patients?

In acute coronary syndromes (ACS), oxidation and inflammation have very important roles and in-vitro studies have demonstrated that gamma-glutamyl transferase (GGT) participates in such oxidative and inflammatory reactions. We aimed to evaluate the prognostic value of baseline serum GGT activity on the development of major adverse cardiac event (MACE) in the follow-up of the patients with ACS in coronary care unit (CCU), after 1 and 6 month periods. We included 117 patients (mean age: 61.2+/-11.3 years, 93 males) hospitalized in CCU with the diagnosis of ACS. All had baseline serum GGT activity and were free of systemic and hepatobiliary disease. MACE was defined as the composite of mortality from cardiac causes, recurrent hospitalization with ACS and nonfatal recurrent myocardial infarction diagnoses, to need for coronary revascularization during CCU, over 1 and 6 month follow-up periods. During the follow-up of CCU, MACE occurred in 17 (14.5%) patients (two died). Serum GGT activity was significantly higher in the patients with MACE than those free of MACE (P=0.001) and GGT was found as the independent predictor of the development of MACE-CCU [relative hazard: 1.05, 95% confidence interval (CI): 1.01-1.09, P=0.007]. During the follow-up of 1 month, MACE occurred in 23 (20.0%) patients (five died). Serum GGT activity was significantly higher in patients with MACE than those free of MACE (P=0.021) and GGT was found as the independent predictor of the development of MACE-1 month (relative hazard: 1.04, 95% CI: 1.01-1.08, P=0.039). During the follow-up of 6 months, MACE occurred in 24 (21.8%) patients (two died). Again, GGT was significantly higher in patients who developed MACE than those free of MACE (P=0.001) and GGT was found as the independent predictor of the development of MACE-6 months (relative hazard 1.06, 95% CI: 1.03-1.10, P<0.001). Serum GGT activity was found to be an independent predictor of the development of MACE in the patients with ACS during CCU, over 1 and 6 month follow-up periods.