Increased plasma asymmetric dimethylarginine level is associated with ascending aorta dilatation: a case-control study.

BACKGROUND: Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor of nitric oxide synthase. AIM: We aimed to determine plasma ADMA levels in patients with ascending aorta dilatation in comparison to those without aorta dilatation, and to evaluate the diagnostic, predictive, and prognostic value of serum ADMA level for aorta dilatation. METHODS: This was a cross-sectional case-control study. A total of 104 consecutive patients (female/male, 35/69; mean age, 62.75 ± 13.11 years) diagnosed with ascending aorta dilatation (≥ 4.5 cm) on echocardiography (case group), and 52 age-and gender-matched patients (female/male, 17/35; mean age, 63.44 ± 7.56 years) with normal aorta dimensions (≤ 3.8 cm) (control group) were included. Routine biochemical and haematological analysis in addition to measurement of serum ADMA level were performed. RESULTS: The mean diameter of ascending aorta measured on echocardiography was 4.95 ± 0.57 cm and 3.34 ± 0.36 cm in patients with aorta dilatation and those without aorta dilatation, respectively (p < 0.001). Serum ADMA level was significantly higher in patients with aorta dilatation than in the control group (1.70 ± 1.12 µmol/L vs. 0.79 ± 0.76 µmol/L, respectively, p < 0.001). There was significant positive correlation between ADMA level and aortic diameter in Spearman correlation analysis (r = 0.317, p < 0.001). In linear regression analysis, ADMA was found to be a significant independent predictor of aorta diameter (Beta = 0.26, p < 0.001). Receiver-operator characteristic curve analysis also revealed that serum ADMA cut-off level over 0.29 µmol/L predicts aorta dilatation (≥ 4.5 cm) with 94% sensitivity and 92% specificity and with high ac-curacy (area under curve: 0.786; 95% confidence interval: 0.709-0.863, p < 0.001). CONCLUSIONS: Serum ADMA level is diagnostic for ascending aorta dilatation with high sensitivity and specificity, and should be considered for use in clinical diagnosis of aorta dilatation.

Predictive values of D-dimer assay, GRACE scores and TIMI scores for adverse outcome in patients with non-ST-segment elevation myocardial infarction.

PURPOSE: To determine the predictive values of D-dimer assay, Global Registry of Acute Coronary Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) risk scores for adverse outcome in patients with non-ST-segment elevation myocardial infarction (NSTEMI). PATIENTS AND METHODS: A total of 234 patients (mean age: 57.2±11.7 years, 75.2% were males) hospitalized with NSTEMI were included. Data on D-dimer assay, GRACE and TIMI risk scores were recorded. Logistic regression analysis was conducted to determine the risk factors predicting increased mortality. RESULTS: Median D-dimer levels were 349.5 (48.0-7,210.0) ng/mL, the average TIMI score was 3.2±1.2 and the GRACE score was 90.4±27.6 with high GRACE scores (>118) in 17.5% of patients. The GRACE score was correlated positively with both the D-dimer assay (r=0.215, P=0.01) and TIMI scores (r=0.504, P=0.000). Multivariate logistic regression analysis revealed that higher creatinine levels (odds ratio =18.465, 95% confidence interval: 1.059-322.084, P=0.046) constituted the only significant predictor of increased mortality risk with no predictive values for age, D-dimer assay, ejection fraction, glucose, hemoglobin A1c, sodium, albumin or total cholesterol levels for mortality. CONCLUSION: Serum creatinine levels constituted the sole independent determinant of mortality risk, with no significant values for D-dimer assay, GRACE or TIMI scores for predicting the risk of mortality in NSTEMI patients.

Comparison of Edwards Sapien XT versus Lotus Valve Devices in Terms of Electrophysiological Study Parameters in Patients Undergoing TAVI.

BACKGROUND: The purpose of this study is to assess the electrocardiographic and electrophysiological parameters of conduction abnormalities in patients undergoing transcatheter aortic valve implantation (TAVI) due to severe aortic valve stenosis. METHODS: The study included 55 patients who underwent TAVI using either the Boston Scientific Lotus (n:25) (Boston Scientific, Natick, MA, USA) or Edwards Sapien XT (n:30) (Edwards Lifesciences, Irvine, CA, USA) prostheses. An electrophysiological study (EPS) was performed in the catheterization room immediately before the initial balloon valvuloplasty and immediately after prosthesis implantation. RESULTS: QRS duration and His-bundle to His-ventricle (HV) intervals, which were similar between the two groups before the procedure, were found to be significantly higher in the Lotus valve group postprocedure. Permanent pacemakers (PPMs) were required more frequently in the Lotus group than in the Sapien XT group at discharge (24.0% vs 6.7%, P = 0.07). With the exception of a higher prevalence of paravalvular leakage (P < 0.001) in patients undergoing Sapien XT implantation, other clinical outcomes were similar between the two groups. Multiple regression analysis revealed that baseline atrioventricular (AV) conduction disorders and HV intervals after the procedure were independently associated with PPM implantation after TAVI. CONCLUSION: In this first study comparing the findings of EPS and electrocardiography, the impact of the Lotus valve on AV conduction systems was greater than that of the Sapien XT. However, the need for PPM was higher in the Lotus valve than in the Sapien XT. PPM requirement is related to valve design; it may decrease with reduced frame height and metal burden in novel valve systems.

Long-term prognostic significance of admission plateletcrit values in patients with non-ST elevation myocardial infarction.

The plateletcrit has been investigated as a new predictor of cardiovascular risk. The objective of our study was to investigate the role of admission plateletcrit in predicting long-term cardiovascular mortality in patients presenting with non-ST-segment elevation myocardial infarction (NSTEMI). We enrolled 296 patients with NSTEMI (mean age 59.2 ±â€Š11.8 years; 228 men, 68 women) in this study. The study population was divided into tertiles on the basis of admission plateletcrit values. A high plateletcrit (n = 98) was defined as a value in the upper third tertile (plateletcrit >0.23), and a low plateletcrit (n = 198) was defined as any value in the lower two tertiles (plateletcrit ≤0.23). The median follow-up time was 38 months. In multivariate analyses, a significant association was noted between high plateletcrit values and the adjusted risk of long-term mortality (odds ratio = 12.15, 95% confidence interval = 1.78-82.77; P < 0.001). In the Kaplan-Meier survival analysis, the long-term mortality rate was 20.4% in the high plateletcrit group versus 4.5% in the low plateletcrit group (P < 0.001). Long-term major advanced cardiac events (MACE), hospitalization for heart failure and reinfarction were significantly higher in patients with high plateletcrit. Admission plateletcrit is a strong and independent predictor of long-term cardiovascular mortality in patients with NSTEMI.

Relation of platelet indices to severity of coronary artery disease in patients undergoing primary percutaneous coronary intervention.

AIM: We investigated the association between platelet indices and the severity of coronary artery disease (CAD) in patients with ST-segment-elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PPCI). METHODS: A total of 484 consecutive patients who were routinely referred to coronary angiography for STEMI and 81 age- and gender-matched patients with normal coronary arteries were included in the present study. We analyzed the relation between the platelet distribution width (PDW) and the angiographic severity of CAD. The SYNTAX score was used for assessing the severity of coronary atherosclerosis. RESULTS: The mean platelet volume (MPV), the plateletcrit (PCT) and the neutrophil levels were significantly higher in the STEMI group than in the control group. Patients with an elevated SYNTAX score (>32) had higher PDW values. The levels of plateletcrit and the estimated glomerular filtration rate (eGFR) were lower in the high SYNTAX score group compared to the moderate-to-low SYNTAX score group. The PDW was positively correlated with age (r = 0.128, p=0.004) and SYNTAX score (r = 0.209, p<0.001). There was a mild, significant inverse association between the PDW level and the eGFR (r = -0.101, p=0.049), the mean platelet volume (MPV) (r = -290, p<0.001) and the PCT (r = -345, p<001). Using multivariate logistic regression analysis, we found that age (OR = 1.046, 95% CI 1.013-1.079, p=0.005), diabetes (OR = 4.779, 95% CI 2.339-9.767, p<0.001) and PDW (OR = 1.229, 95% CI 1.072-1409, p=0.003) were independent correlates of high SYNTAX score. CONCLUSION: Platelet distribution width, an inexpensive and easily measurable laboratory variable, is independently associated with high SYNTAX score.

Assessment of Mean Platelet Volume in Patients with Resistant Hypertension, Controlled Hypertension and Normotensives.

OBJECTIVE: Patients with resistant hypertension are at increased risk for cardiovascular events. Mean platelet volume (MPV) is an accepted biomarker of platelet activation and considered as a risk factor for cardiovascular disease. The aim of this study was to determine whether MPV levels are higher in resistant hypertensive (RHTN) patients than in controlled hypertensive (CHTN) patients and healthy normotensive controls. MATERIALS AND METHODS: 279 consecutive patients were included in this study. Patients were divided into three groups: Resistant hypertension patient group [n=78; mean age 56.8±9.8; 42 males (53.8%)]; controlled hypertension patient group [n=121; mean age 54.1±9.6; 49 males (40.5%)]; and normotensive control group [n=80; mean age 49.8±8.5; 34 males (42.5%)]. Physical examination, laboratory work-up, and 24-hour ambulatory blood pressure measurement (ABPM) were performed in all participants. RESULTS: The mean platelet volume levels were significantly higher in RHTN group than in the CHTN and normotensive groups (p<0.001). In correlation analysis office systolic and diastolic blood pressure was positively correlated with MPV. CONCLUSION: Our study demonstrated that MPV, as an important indicator of platelet activation, was statistically higher in RHTN patients than in CHTN and in normotensive subjects. Elevated MPV levels may help to determine a high risk group for atherosclerosis in RHTN patients.

The assessment of relationship between fragmented QRS complex and left ventricular wall motion score index in patients with ST elevation myocardial infarction who underwent primary percutaneous coronary intervention.

OBJECTIVES: Fragmented QRS (fQRS) has been found to be associated with high mortality and arrhythmic events in acute coronary syndromes. Regional systolic function using wall motion score index (WMSI) is an alternative to left ventricular ejection fraction (LVEF) for the assessment of left ventricular systolic function. The aim of this study was to investigate the relation between the presence of fQRS on admission electrocardiogram (ECG) and WMSI in ST elevation myocardial infarction (STEMI) underwent primary coronary intervention (PCI). The in-hospital and long-term prognostic significance of persistent fQRS was also evaluated. METHODS: In this retrospective study, 542 patients with a diagnose of STEMI underwent primary PCI were included. Study patients were divided into two groups according to the presence (n = 153) or absence (n = 389) of a fQRS on admission ECG. RESULTS: WMSI was found to be significantly higher in fQRS(+) group compared to the fQRS(-) group (P < 0.001). In multivariete analysis, WMSI was found to be an independent predictor of fQRS, and fQRS was inversely associated with LVEF. The in-hospital reinfarction (P = 0.003), MACE (P = 0.024), intraaortic balloon pump use (P = 0.014), and advanced heart failure (P < 0.001) were found to be significantly more frequent in the fQRS(+) group. The presence of fQRS on admission was found to be associated with an increase in long-term cardiovascular mortality (P = 0.028), and long-term all-cause mortality (P = 0.022). CONCLUSION: WMSI was significantly related with the presence of the fQRS, which reflects the linking between impairment of regional left ventricular systolic function and the presence of severe myocardial injury in STEMI.

Assessment of the relationship between nondipping phenomenon and microvolt T-wave alternans.

OBJECTIVE: The aim of this cross-sectional study was to evaluate microvolt T-wave alternans (MTWA) as a marker of myocardial electrical instability in normotensive and hypertensive individuals with either nondipper or dipper-type circadian rhythm of blood pressure. MATERIALS AND METHODS: The study group included a total of 181 patients: 118 hypertensive patients and 63 normotensive healthy volunteers [mean age 46 ± 8; 34 men (54%)]. The patients with hypertension were divided into two groups on the basis of their results of 24-h ambulatory blood pressure monitoring: 61 patients with dipper hypertension [mean age 46 ± 6; 32 men (52.5%)] and 57 patients with nondipper hypertension [mean age 48 ± 10; 36 men (63.2%)]. The MTWAs of all patients were analyzed using the time-domain modified moving average method by means of a treadmill exercise stress test. RESULTS: MTWA positivity was statistically significantly different between all groups. Left ventricular mass index, E/E', interventricular septum, posterior wall, 24-h systolic blood pressure and diastolic blood pressure, and night-time systolic blood pressure and diastolic blood pressure were correlated positively with MTWA. Left ventricular mass index and the presence of nondipper hypertension were determined to be independent predictors of MTWA positivity. CONCLUSION: The blunting of the nocturnal decrease in blood pressure was associated with MTWA positivity in hypertensive patients.

Assessment of mean platelet volume and soluble CD40 ligand levels in patients with non-dipper hypertension, dippers and normotensives.

UNLABELLED: Abstract Objective: Patients with a lack of nocturnal decline in blood pressure (BP) are at an increased risk for cardiovascular events. Mean platelet volume (MPV) and soluble CD40 ligand (sCD40L) are accepted biomarkers of platelet activation and considered as a risk factor for cardiovascular disease. The aim of this study was to determine whether MPV and sCD40L levels are higher in non-dipper hypertensive (NDHT) patients than in dipper hypertensive (DHT) patients and healthy controls. METHODS: 124 consecutive patients were included to this study. Patients were divided into three groups: NDHT patient group [n = 43; mean age 51.8 ± 6.6; 31 males (72.1%)]; DHT patient group [n = 41; mean age 50.2 ± 7.3; 22 males (53.7%)]; and normotensive group [n = 40; mean age 49.9 ± 6.7; 22 males (55%)]. Physical examination, laboratory work-up and 24-h ABPM were performed for all participants. RESULTS: The sCD40L and MPV levels were significantly higher in the NDHT group than in the DHT and normotensive groups (p < 0.05). In correlation analysis, MPV, 24-h systolic blood pressure (SBP), 24-h diastolic blood pressure (DBP), night-time SBP and night-time DBP were positively correlated with sCD40L. CONCLUSION: Our study demonstrated that MPV and sCD40L levels were significantly higher in NDHT patients compared to DHT and normotensive patients. sCD40L levels were positively correlated with MPV, 24-h SBP, 24-h DBP, night-time SBP and night-time DBP.

The assessment of relationship between left ventricular geometry and microvolt T-wave alternans in sustained hypertension.

OBJECTIVE: Left ventricular (LV) hypertrophy (LVH) predicts increased mortality in part due to an elevated incidence of sudden cardiac death in hypertension. The aim of the present study was to investigate the relation of microvolt T-wave alternans (MTWA) with different LV geometric patterns in patient with sustained hypertension. METHODS: This study consisted of 311 consecutive patients with sustained hypertension who were divided into four groups according to LV geometrical patterns. 90 patients were in the normal geometry group (NGG) [mean age 49.6 ± 7.8 years; 60 males (66.7%)], 99 patients were in the concentric remodeling group (CRG) [mean age 50.9 ± 6.6 years; 50 males (50.6%)], 63 patients were in the concentric hypertrophy group (CHG) [mean age 51.6 ± 7.3 years; 32 males (50.7%)] and 58 patients were in the eccentric hypertrophy group (EHG) [mean age 51.6 ± 9.0 years; 30 males (51.7%)]. Physical examination, laboratory work-up, office blood pressure measurement, transthoracic echocardiography and MTWA measurements were performed on all participants. RESULTS: MTWA positivity was significantly higher in EHG and CHG as compared to CRG and NGG (p < 0.001). Left ventricle mass index (LVMI), LV end-diastolic diameter (LVEDD), LV end-systolic diameter (LVESD), interventricular septum diameter (IVSd), posterior wall diameter (PWd) and office systolic blood pressure (SBP) were found to be significantly positively correlated with MTWA (all p-values < 0.05). CONCLUSION: We demonstrated that increased LVMI is associated with an elevated MTWA positivity in sustained hypertensives. Moreover, clinically significant LV geometric patterns including both concentric and eccentric hypertrophy are related with a raised MTWA positivity, which may lead to particular predilection to life-threatening ventricular arrhythmias and sudden cardiac death in sustained hypertension.

Effects of percutaneous closure of atrial septal defect on left atrial mechanical and conduction functions.

AIMS: Atrial septal defect (ASD) is one of the most common congenital heart diseases in adults. We prospectively evaluated early and mid-term effects of the percutaneous closure of secundum ASD on atrial electromechanical delay (AEMD) and left atrial (LA) mechanical functions at the first day and sixth month in patients undergoing percutaneous closure. METHODS AND RESULTS: Forty-one patients were included in this study. Twenty-six (63.4%) of the 41 patients were female and the mean age was 41 ± 13 years. All the patients had echocardiographic examination before the procedure and at the first day and sixth month after the procedure. LA volumes (maximal, minimal, and presystolic) and EMD (lateral, septal, and tricuspid) were measured. Left and right intra- and inter-AEMD were not changed at the first day but both were significantly shorter at the sixth month. There was no change in the total emptying volume and fraction before and after the procedure. LA maximal, minimal, and pre-systolic volumes, active emptying volume, and fractions were decreased at the first day and at the sixth month compared with pre-procedural volumes. LA passive emptying volume, passive emptying fraction, and conduit volume were increased at the first day and at the sixth month compared with pre-procedural volumes. CONCLUSION: Our results revealed that there was no change in the LA mechanical reservoir functions, but improved conduit function and impaired contractility functions early and in the mid-term after percutaneous closure of ASD and decreased AEMD only in the mid-term.

Hematologic and clinical parameters after transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis.

BACKGROUND: Previous studies have demonstrated that platelet activation occurs in patients with aortic stenosis (AS). This study sought to evaluate the changes in hematologic and clinical parameters noted with the improvement in AS following transcatheter aortic valve implantation (TAVI) in patients with severe AS at high risk of surgery. PATIENTS AND METHODS: The study included 33 patients who underwent TAVI. In addition to biochemical, clinical, and echocardiographic examinations, hematologic blood parameters were recorded before TAVI, at discharge, and at 1 and 4 months. RESULTS: Mean platelet volume (MPV) showed a progressive decrease after TAVI. On echocardiography at 1 month, aortic valve area significantly increased, with significant decreases in peak and mean gradients. Progressive decreases were also noted in N-terminal proB-type natriuretic peptide levels. CONCLUSION: Our findings show that TAVI improves hemodynamic parameters of the valve with marked clinical and echocardiographic improvement, resulting in decreased platelet activation and MPV in patients with severe AS.

The Effect of Slow Coronary Artery Flow on Microvolt T-Wave Alternans.

BACKGROUND: Slow coronary artery flow (SCF) is characterized by angiographically confirmed delayed vessel opacification in the absence of any evidence of obstructive epicardial coronary artery disease. Microvolt T-wave alternans (MTWA) is defined as beat-to-beat changes in shape, amplitude, or timing of ST segments and T waves, and is utilized in predicting sudden cardiac death and life-threatening malign ventricular arrhythmias in high-risk patients. In our study, we aimed to evaluate the effects of slow coronary artery flow on MTWA. METHODS: Thirty-nine consecutive patients (SCF group: 6 women and 33 men; mean age, 49 ± 10 years) with angiographally documented SCF in at least 1 major epicardial artery and 39 patients (control group: 13 women and 26 men; mean age, 50 ± 10 years) with normal coronary arteries were included in the study. Coronary flow rates of all patients were calculated by thrombolysis in myocardial infarction frame count (TFC). The MTWAs of all patients were analyzed using the time-domain modified moving average method by means of a treadmill exercise stress test. RESULTS: The age distribution , body mass index, and diastolic and systolic blood pressure (BP) were similar in the SCF and control group. In the SCF group, the three epicardial coronary artery corrected TFCs and mean TFCs were significantly higher than in the control group (for all, p < 0.001). MTWA positivity in the SCF group was statistically significant compared to the control group (p = 0.006). Spearman's correlation analysis, showed a positive correlation between MTWA and right coronary artery (RCA) TFC and mean TFC (r = 0.368, p = 0.001 and r = 0.271, p = 0.016, respectively). In linear regression analysis, only the right coronary artery TFC was correlated with positive MTWA (p = 0.001). CONCLUSIONS: The results of our study suggest that diagnosed SCF is associated with MTWA positivity. Furthermore, we determined that only RCA TFC was predictive of positive MTWA. KEY WORDS: Microvolt T-wave alternans; Slow coronary flow.

Electrophysiological evaluation of atrioventricular conduction disturbances in transcatheter aortic valve implantation with Edwards SAPIEN prosthesis.

AIMS: Permanent pacemaker requirement is a known complication after transcatheter aortic valve implantation (TAVI). The aim of the present study was to analyze the effects of Edwards SAPIEN prosthesis implantation on atrioventricular conduction. METHODS: The study included 28 patients who underwent TAVI due to severe aortic valve stenosis. An electrophysiological study was performed in the catheterization room immediately before the initial balloon valvuloplasty and immediately after Edwards SAPIEN prosthesis implantation. RESULTS: His-ventricle interval was significantly prolonged postprocedure (55.9 ± 11.5 ms) vs preprocedure (47.3 ± 7.8 ms) (P<.001). The antegrade Wenckebach point was observed to be significantly prolonged postprocedure (354.4 ± 41.3 ms) vs preprocedure (333.7 ± 45.4 ms) (P=.001). Despite atrial-His interval prolongation, it was not statistically significant. After the procedure, we observed significant conduction disturbances in 3 patients (10.7%). These conduction problems recovered before discharge. One of the patients (3.6%) with right bundle branch block + left anterior fascicular block required permanent pacemaker implantation. At postprocedure electrocardiogram, QRS duration increased, QRS axis shifted to the left, and both of the values became normal before discharge. The patient's echocardiographic and clinical parameters were improved during follow-up. CONCLUSION: The effect of Edwards SAPIEN on the conduction system was mostly infranodal and temporary. The physical properties of the Edwards SAPIEN prosthesis may explain this observation. This complication may be lessened if the frame height characteristics can be improved.

Association of neutrophil to lymphocyte ratio with presence of isolated coronary artery ectasia.

OBJECTIVES: Coronary artery ectasia (CAE) has been defined as a dilated artery luminal diameter that is at least 50% greater than the diameter of the normal portion of the artery. Isolated CAE is defined as CAE without significant coronary artery stenosis and isolated CAE has more pronounced inflammatory symptoms. Neutrophil to lymphocyte ratio (NLR) is widely used as a marker of inflammation and an indicator of cardiovascular outcomes in patients with coronary artery disease. We examined a possible association between NLR and the presence of isolated CAE. STUDY DESIGN: In this study, 2345 patients who underwent coronary angiography for suspected or known ischemic heart disease were evaluated retrospectively. Following the application of exclusion criteria, our study population consisted of 81 CAE patients and 85 age- and gender-matched subjects who proved to have normal coronary angiograms. Baseline neutrophil, lymphocyte and other hematologic indices were measured routinely prior to the coronary angiography. RESULTS: Patients with angiographic isolated CAE had significantly elevated NLR when compared to the patients with normal coronary artery pathology (3.39 ± 1.36 vs. 2.25 ± 0.58, p<0.001). A NLR level >= 2.37 measured on admission had a 77% sensitivity and 63% specificity in predicting isolated CAE at ROC curve analysis. In the multivariate analysis, hypercholesterolemia (OR=2.63, 95% CI 1.22-5.65, p=0.01), obesity (OR=3.76, 95% CI 1.43-9.87, p=0.007) and increased NLR (OR=6.03, 95% CI 2.61-13.94, p<0.001) were independent predictors for the presence of isolated CAE. CONCLUSION: Neutrophil to lymphocyte ratio is a readily available clinical laboratory value that is associated with the presence of isolated CAE.

The relationship between γ-glutamyl transferase levels and the clinical outcomes in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

OBJECTIVES: Serum γ-glutamyl transferase (GGT) activity has been shown to be related to the development of atherosclerosis and cardiovascular events. The aim of this study was to evaluate the prognostic value of GGT in patients with ST-segment elevation myocardial infarction (STEMI) undergoing a primary percutaneous coronary intervention (PCI). PATIENTS AND METHODS: A total of 683 consecutive patients with STEMI who underwent primary PCI were evaluated. The study population was divided into tertiles on the basis of admission GGT values. A high GGT (n=221) was defined as a value in the upper third tertile (GGT>37) and a low GGT (n=462) was defined as any value in the lower two tertiles (GGT≤37). The mean follow-up time was 29 months. RESULTS: The in-hospital mortality rate was significantly higher in patients in the high GGT group (7.2 vs. 1.7%, P<0.001), as was the rate of adverse outcomes in patients with high GGT levels. In multivariate analyses, a significant association was found between high GGT levels and adjusted risk of in-hospital cardiovascular mortality (odds ratio=8.6, 95% confidence interval: 2.3-32.4, P=0.001). In a receiver operating characteristic curve analysis, a GGT value greater than 37 was identified as an effective cutoff point in STEMI for in-hospital cardiovascular mortality (area under curve=0.71, 95% confidence interval: 0.59-0.82, P<0.001). There were no differences in the long-term adverse outcome rates between the two groups. CONCLUSION: GGT is a readily available clinical laboratory value associated with in-hospital adverse outcomes in patients with STEMI who undergo primary PCI. However, there was no association with long-term mortality.

Transcatheter aortic valve implantation through a left aortoiliac graft.

The indications for transcatheter aortic valve implantation have been increasing with the development of new-generation valves and delivery systems. Our patient, an 81-year-old man with aortic stenosis, had an existing coronary artery bypass graft and bilateral aortoiliac bypass grafts. We used the transfemoral approach through the left femoral artery and the left aortoiliac graft to successfully deploy a new-generation Edwards SAPIEN valve.

Myocardial ischemia in severe aortic regurgitation despite angiographically normal coronary arteries.

Patients with severe aortic regurgitation frequently present with angina pectoris. The exact pathophysiology for angina in aortic regurgitation is not clear. Left ventricular hypertrophy and myocardial blood supply-demand mismatch have been the suggested mechanisms to explain ischemia. However, no conclusive clinical study exists to define the incidence of ischemia in patients with severe aortic regurgitation and normal coronary arteries. We, therefore, investigated the frequency of myocardial ischemia in relation to left ventricular hypertrophy or dilatation in patients with severe aortic regurgitation and normal coronary arteries. We reviewed the medical records of all patients (n = 311) with aortic valve replacement due to aortic regurgitation between 2007 and 2010. We selected subjects with normal coronary arteries (n =182) for the study purpose, and we identified 35 patients who underwent myocardial perfusion scintigraphy prior to the coronary angiography (19 female and 16 male subjects; age 45.0 ± 8.9 years). Left ventricular hypertrophy and dilatation were detected in 9 (26%) and 5 (14%) patients, respectively. Myocardial perfusion scintigraphy showed evidence of ischemia in 10 (29%) patients with normal coronary arteries. The presence of ischemia did not relate to the presence of left ventricular hypertrophy and/or dilatation. As a potential mechanism, aortic regurgitation causes backflow of blood from the aorta into the left ventricle, hence disturbs coronary flow dynamics. In conclusion, myocardial ischemia is common (nearly one-third) among patients with severe aortic regurgitation even in the absence of coronary obstruction, left ventricular hypertrophy and/or dilatation.

The effects of blood pressure lowering on P-wave dispersion in patients with hypertensive crisis in emergency setting.

Hypertensive emergency refers to a severe hypertension (HT) that is associated with new or progressive end-organ damage. In these clinical situations, blood pressure (BP) should be reduced immediately to prevent or minimize organ dysfunction. The present study evaluated the diagnostic value of two electrocardiographic indices in detecting patients, who are at risk for paroxysmal atrial fibrillation (PAF), in the setting hypertensive crisis. The study population consisted of 30 consecutive patients aged ≥40 years, who were admitted to the emergency room with hypertensive crisis. Electrocardiographic (ECG) recordings of the patients were performed before and after the treatment. The minimum (Pmin) and maximum (Pmax) P wave duration on ECG, and P-wave dispersion (P(d)), which was defined as the difference between Pmin and Pmax, were measured. The mean P(d) was 118.0 ± 32.1 and 94.0 ± 44.3 before and after the treatment, respectively. The decrease observed in the mean P(d) was statistically significant (p = 0.005). The mean Pmax was 214.7 ± 37.1 before the treatment, while it was 194.0 ± 47.3 after the treatment, and the difference was significant (p = 0.021). The mean Pmin was 96.7 ± 26.3 and 100.0 ± 41.0 before and after the treatment, respectively; however, the difference was not significant (p = 0.624). Pmax and P(d) display significant changes with acute treatment of HT. There is a need for larger prospective studies to clearly elucidate the diagnostic value of ECG indices, Pmax and P(d) as indicators of future PAF.