The relationship between high-sensitive troponin T, neutrophil lymphocyte ratio and SYNTAX Score.

AIM: Cardiac troponins are the most preferred biomarkers in the evaluation of acute coronary syndromes (ACS). The aim of our study was to examine the association between high sensitive troponin T (hs-TnT), and neutrophil to lymphocyte ratio (NLR) and the complexity of ACS assessed by SYNTAX Score. METHODS AND RESULTS: 287 patients who underwent coronary angiography were studied (215 male, mean age 62.0 ± 12.7 years). 133 patients were ST elevation myocardial infarction (STEMI), 154 patients were non-ST elevation (NSTE) ACS . The patients are divided to tertiles according to SYNTAX Score; SYNTAX Score ≤ 22 (n = 122) 22 < SYNTAX Score ≤ 32 (n = 120), and SYNTAX Score > 32 (n = 45). NLR was significantly correlated with SYNTAX Score in both STEMI and NSTE-ACS groups (r = 0.254, p = 0.003, r = 0.419 p < 0.001). Multiple linear regression analysis showed NLR predicted the angiographic severity of ACS assessed by SYNTAX Score in two groups (ß = 0.231, p = 0.004; ß = 0.232, p = 0.003). Hs-TnT was significantly correlated with SYNTAX Score in two groups (r = 0.327, p < 0.001; r = 0.430, p < 0.001). Multiple linear regression analysis showed hs-TnT was independent predictor of SYNTAX Score in STEMI and NSTE-ACS patients (ß = 0.292, p < 0.001; ß = 0.317, p < 0.001). CONCLUSION: Hs-TnT and NLR were significantly correlated with angiographic severity of ACS assessed by SYNTAX Score.

Epicardial adipose tissue thickness in hemodialysis patients.

AIM: Hemodialysis (HD) patients had higher cardiovascular mortality and it is related to atherosclerosis. Epicardial adipose tissue (EAT) thickness is a marker of atherosclerosis and independent predictor of coronary artery disease. The aim of our study was to evaluate the relationship between EAT and carotid intima-media thickness (CIMT) predictors of early atherosclerosis in HD patients. METHODS: The study included 62 HD patients and 40 healthy controls. EAT thickness and CIMT were measured by echocardiography in all subjects. RESULTS: Epicardial adipose tissue thickness and CIMT were higher (6.98 ± 1.67 vs. 3.84 ± 0.73 mm, P < 0.001, 0.94 ± 0.17 vs. 0.63 ± 0.11 mm, P < 0.001, respectively) in HD patients than in control subjects. EAT thickness were correlated with CIMT, HD duration, age, and calcium. In addition, HD duration, CIMT, and age were independent predictors of EAT thickness on HD patients in regression analysis. CONCLUSION: Epicardial adipose tissue thickness may be a useful indicator of early atherosclerosis in HD patients.

Intercellular adhesion molecule-1 K469E and angiotensinogen T207M polymorphisms in coronary slow flow.

OBJECTIVE: To investigate intercellular adhesion molecule-1 (ICAM1) and angiotensinogen (AGT) gene polymorphisms, as related to atherosclerosis and endothelial dysfunction, in coronary slow flow (CSF). SUBJECTS AND METHODS: The participants in this study were 48 patients with CSF and 67 patients with normal coronary flow as controls. The K469E polymorphism of ICAM1 (rs5498) and the T207M polymorphism of AGT (rs4762) were determined using the polymerase chain reaction amplification method. RESULTS: Baseline demographic parameters were similar in both groups. The mean thrombolysis in myocardial infarction frame count was significantly higher in patients with CSF (23.8 ± 5.1) compared to the controls (13.3 ± 2.6, p < 0.001). A significant association was found between the ICAM1 K allele and CSF (OR: 1.96, 95% CI: 1.15-3.35, p = 0.013). There was no difference in the frequency of AGT T207M genotypes in the patients with CSF and the control subjects. CONCLUSION: This study showed that K469E polymorphisms of ICAM1 that play a role in atherosclerotic pathogenesis are related to CSF.

The effect of aspirin on mean platelet volume in patients with paroxysmal atrial fibrillation.

Aspirin is one of the preferred therapies in the primary prevention of ischemic stroke in paroxysmal atrial fibrillation (PAF). Mean platelet volume (MPV) is a marker of platelet size and activation. Increased MPV reflects active and large platelets. The present observational study was designed to investigate whether aspirin treatment does affect MPV levels in patients with PAF. The study included 101 patients who were detected to have PAF by 24-hour Holter monitoring and divided into two groups based on aspirin treatment [ASA (+) and ASA (-)]. MPV was measured. Patients with aortic and mitral stenosis, hyperthyroidism, hypothyroidism, malignancy, infection, and pregnancy were excluded from the study. Of the 101 patients, 50 had no antiplatelet therapy and 51 had daily aspirin (100 mg) intake. Mean age of the patients was 66 ± 10 years and 35 (68%) were male in ASA (+) group. There was no difference in median levels of MPV (9.9 vs. 10.2 fl, respectively; p = 0.9) between groups. Both uni- and multivariate logistic regression analyses did not show an association between MPV and ASA use. Our results indicate that MPV as a predictive marker of platelet size and activity is not affected by aspirin use in patients with PAF.

Relation of serum cortisol to delirium occurring after acute coronary syndromes.

BACKGROUND: Delirium can be associated with cardiac system disorders. Stress plays an important role in the pathogenesis of postoperative delirium. Cortisol is one of the most important stress hormones in humans. We aimed to investigate whether a relation exists between serum cortisol and the degree of delirium after acute coronary syndromes (ACS). METHODS: We enrolled 52 consecutive patients who presented with ACS and were hospitalized in the coronary care unit. Patients were examined daily by a single psychiatrist, and delirium was diagnosed by using the Delirium Rating Scale (DSR). Blood samples were obtained at 6:00 am of the next morning after admission. RESULTS: The mean age was 66 years (SD, ±6 years), and 52% were men. Delirium occurred in 25 patients (48%). The median score on the DRS was 17 for the delirious patients and 5 for the nondelirious. Median cortisol levels were significantly different between the delirium and nondelirium groups (13.9 vs 6.2 µg/dL; P < .01). There were significant correlations between the cortisol levels and the severity of the delirium based on DRS scores as well as between the cortisol levels and the presence of delirium (r = 0.65 and 0.74, respectively; P = .01). In a linear logistic regression model, cortisol predicted the occurrence of delirium (ß = .81; P < .01). In receiver operating characteristics analysis, the optimal cutoff value of cortisol to predict delirium was 10.8 µg/dL, with 96% sensitivity and 89% specificity. CONCLUSION: Delirium was common after ACS, and serum cortisol levels correlated with the degree of delirium and the risk of delirium.

Hemodynamic effects of left upper extremity arteriovenous fistula on ipsilateral internal mammary coronary artery bypass graft.

OBJECTIVE: Arteriovenous fistula (AVF) in patients undergoing hemodialysis (HD) may cause coronary left internal mammary artery (IMA) steal. This phenomenon was demonstrated by few prospective studies with limited number of patients and case reports. We aimed to demonstrate with a relatively larger patient population that the AVF may cause ipsilateral IMA steal. METHODS: We included 22 prospective patients undergoing HD who had left IMA to left anterior descending artery graft and left upper limb AVF. Right IMA was taken as control. Flows were assessed by using color Doppler ultrasonography. RESULTS: The mean age was 57.8 ± 9 years. Statistically nonsignificant increases in AVF flow and decreases in left IMA flow were observed during HD compared with pre-HD. Moreover, fistula localization did not affect median left IMA flows (for peak systolic velocity [PSV] 43.7 versus 70 cm/s, respectively; p = 0.7, and for end diastolic velocity [EDV] 3.4 versus 6.5 cm/s, respectively; p = 0.7). We have not detected significant difference in left IMA flows during HD (median values of PSV 58.4 versus 68.4 cm/s, respectively; p = 0.1, and EDV 6.4 versus 4.4 cm/s, respectively; p = 0.08). Only three patients experienced dialysis-induced reduction of ipsilateral IMA flow that was accompanied by evidence of hypokinesia of the anterior left ventricular wall without clinical angina. CONCLUSIONS: Hemodynamically affected left IMA flow by ipsilateral upper extremity AVF may cause steal phenomenon. Hemodynamic differences between left and right IMAs in patients undergoing HD via left wrist and brachial fistulae are limited.

Could epicardial adipose tissue thickness by echocardiography be correlated with acute coronary syndrome risk scores.

AIM: The aim of our study was, echocardiographic epicardial adipose tissue (EAT) thickness could show the severity and the prognosis of acute coronary syndromes (ACS). METHODS AND RESULTS: Sixty-five ACS patients (mean age 57.4 ± 12.2 years) who underwent coronary angiography were studied. EAT thickness on the free wall of right ventricle was measured at end-diastole from the parasternal long-axis views of 3 cardiac cycles. SYNTAX and Global Registry of Acute Coronary Events (GRACE) scoring considered for severity and the prognosis of ACS. The mean value of the EAT thickness were 5.5 ± 0.5 mm (range 1-12 mm). EAT thickness had a positive correlation with high sensitive troponin T (r = 0.712, P < 0.001) and body mass index (r = 0.522, P < 0.001.) EAT thickness was significantly correlated patients with high SYNTAX score (r = 0.690, P < 0.001), but not correlated with GRACE score (r = 0.224, P = 0.072). CONCLUSION: Epicardial adipose tissue thickness was correlated with angiographic severity of ACS, but not correlated with clinical prognosis risk score.

Pre- and perioperative risk factors predicting neurologic outcomes after coronary artery bypass surgery in patients with pre-existing neurologic events.

BACKGROUND: A neurologic event (NE) after coronary artery bypass graft (CABG) surgery is a principal complication affecting morbidity and mortality. We investigated the risk factors predicting postoperative NEs and survival in patients with pre-existing NE undergoing CABG. METHODS: Between 2001 and 2012, 3137 patients underwent isolated primary CABG. The data were stored in a computerized database and retrospectively evaluated. Patients were divided into 2 groups based on the existence of preoperative NE (study group; n=126) and without NE (n=3011). Uni- and multivariate logistic regression analyses were performed to evaluate the possible predictors of postoperative NEs. Survival was determined using Kaplan-Meier survival analyses of the study group and propensity score-matched control group. RESULTS: The mean age of the 3137 patients was 60±9 years, and 28% (n=885) were female. Postoperative NE was seen in 4 (3.2%) patients with pre-existing NE and in 16 (0.5%) without pre-existing NE. Preoperative NE (odds ratio 4.47; 95% confidence interval 1.32-15.18; P=.01) and age (≥70 years; odds ratio 2.98; 95% confidence interval 1.21-7.33; P=.01) showed strong multivariate associations with postoperative NE. Median CHA2DS2-VASc scores were 4.5 (interquartile range 3-5) and 3 (range 0-4) in patients in the pre-existing and without NE groups, respectively (P=.01). The overall mean follow-up was 4.6±3 years. Overall survival rates (88.1% and 94%, respectively) were different between the 2 groups (P=.02). CONCLUSIONS: Preoperative neurologic events and advanced age are significant risk factors predicting postoperative neurologic events. Meticulous management of the ascending aorta and carotid artery are important in diminishing postoperative neurologic events. A pre-existing neurologic event is also predictive for decreased overall survival.

Systemic reduced-dose alteplase for diffuse pulmonary thrombi in a COVID-19 patient.

Pulmonary embolism has a high frequency in COVID-19 patients admitted to the intensive care unit. Low level of fibrinolysis is one of the asserted contributors to a prothrombotic state in COVID-19. Thrombotic coagulopathy is mostly encountered as diffuse pulmonary thrombi. Diffuse pulmonary microemboli was treated successfully with reduced dose thrombolysis.

Half-Dose tPA for Massive Pulmonary Thromboembolism After Liposuction.

Background: The most aggressive preventive strategies may fail to prevent pulmonary embolism (PE) after liposuction. PE can cause serious life-threatening consequences and death. If hemodynamic detoriation occurs, treatment is systemic or catheter-directed fibrinolytic therapy and, if failed, surgical embolectomy. A latent risk exists for catastrophic hemorrhage when thrombolytic is administered after surgery. Thus, the use of tissue plasminogen activator (tPA) has never been studied in postoperative patients, and the safety of this medicine is unknown. In this case study, a 31-year-old obese woman was evaluated for complaints of shortness of breath, palpitations, and hypotension in the first postoperative day after liposuction. Conclusions: Successful management of massive PE with a half-dose regimen of tPA (alteplase 50 mg over 2 hours) is reported.

The role of mean platelet volume in predicting thrombotic events.

Studies on platelet function have accelerated and gained popularity since the advent of novel treatment modalities and techniques on atherosclerotic vascular disease, such as antiplatelet drugs and stents. Today it is widely known that platelets exert a fundamental role in inflammation in addition to their long known role in homeostasis and thrombotic events. Interaction with endothelial cells and leukocytes mediates inflammation, contributes to atherogenesis and modulates immune activity. Platelet activation which is a central factor in many arterial disorders may be triggered by multiple pathways. Platelet activation is shown as forming a larger shape, aggregation and releasing various active contents. Mean platelet volume is a marker of platelet size, function and activation. Increased mean platelet volume is shown by active and large platelets that release more thromboxane A2 than smaller ones. The aim of this review is to determine whether early detection of platelet activation via increased mean platelet volume would help to recognize the pro-inflammatory state and administer appropriate and effective treatment properly. An easily detectable marker by using a prompt and functional technique would help our approach to inflammation caused by platelets.

Incidental diagnosis of right-to-left atrial shunt by computed tomography.

The existence and direction of an atrial shunt is normally diagnosed using echocardiography. A right-to-left atrial shunt, uncovered on routine computed tomography angiography, is presented. Transthoracic echocardiography verified the atrial shunt. TTE with intravenous agitated saline revealed the appearance of microbubbles in the left side of the heart. Atrial septal defects are a common cause of congenital heart diseases in adulthood. It may remain silent for decades because of the asymptomatic nature of the disease. Right-to-left atrial shunt is uncommon in patients with ASD.

Moxifloxacin Monotherapy in Left-Sided Staphylococcus aureus Endocarditis.

Staphylococcus aureus is the major cause of endocarditis, and its mortality has remained high despite therapeutic procedures over time. A case of left-sided native valve endocarditis caused by methicillin-sensitive Staphylococcus aureus which responded well to moxifloxacin monotherapy is described. An 83-year-old woman with a history of current hospitalization presented with fatigue and fever. Transthoracic echocardiography depicted vegetation, and blood cultures were positive for Staphylococcus aureus. After a 14-day intravenous administration of moxifloxacin, a good clinical response was achieved, and antibiotic regimen transitioned to oral moxifloxacin for an additional four-week therapy.

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.

Short-term effects of fluvastatin therapy on plasma interleukin-10 levels in patients with chronic heart failure.

BACKGROUND: Experimental data demonstrated that inflammatory mediators, such as pro-inflammatory and anti-inflammatory cytokines and their receptors might have important role in the development and the progression of heart failure (HF). Statins were shown to downregulate inflammatory cytokines in HF. Interleukin (IL)-10 is one of the most important anti-inflammatory cytokines. The effect of statin therapy on plasma IL-10 levels is not known in patients with HF. We conducted this study to investigate the effects of fluvastatin therapy on plasma IL-10 cytokine concentration in patients with HF. METHODS: A total of 29 patients with ischemic HF were included in this prospective uncontrolled study. Patients were assigned to fluvastatin (80 mg/day) after baseline examinations. Determination of biochemical parameters including lipids, IL-10, and tumor necrosis factor-alpha were performed at baseline and 12 weeks after the initiation of fluvastatin therapy. All participants also underwent symptom-limited exercise tolerance test at baseline and 12 weeks, and heart rate recovery (HRR) was calculated. RESULTS: A significant elevation in the plasma levels of IL-10 after 12 weeks of fluvastatin treatment (4.8+ or -1.0 vs. 6.5+ or -1.3 pg/ml, P=0.002) was observed. Plasma tumor necrosis factor-alpha levels were significantly decreased after fluvastatin therapy (6.3+ or -2.3 vs. 4.8+ or -1.4 pg/ml, P=0.003). Fluvastatin therapy significantly improved HRR at 1 min after 12 weeks compared with baseline (19+ or -7 vs. 24+ or -9 bpm, P<0.001). A positive correlation between the change in the levels of IL-10 and the change in HRR at 1 min (r=0.57, P<0.001) was observed. CONCLUSION: Fluvastatin therapy might lead to an increase in plasma IL-10 levels and an associated improvement in vagal tonus as assessed by HRR at 1 min in patients with HF. These findings might partly explain the possible benefit observed in statin trials.

Mean platelet volume is elevated during paroxysmal atrial fibrillation: a marker of increased platelet activation?

Paroxysmal atrial fibrillation might be a risk factor for stroke such as chronic atrial fibrillation. We examined the relation between mean platelet volume and paroxysmal atrial fibrillation to determine the effect of paroxysmal atrial fibrillation on the thrombotic state via elevated mean platelet volume. Mean platelet volume is a marker of platelet size, function, and activation. Increased mean platelet volume reflects active and large platelets that release more thromboxane A2 than smaller ones. We hypothesized that mean platelet volume is elevated in patients with paroxysmal atrial fibrillation. The study population comprised 103 consecutive patients who were detected to have paroxysmal atrial fibrillation by 24-h Holter monitoring and 87 control individuals with normal Holter monitoring. Mean platelet volume and inflammatory parameters were measured. Comprehensive clinical and echocardiographic data were collected. Patients with aortic and mitral stenosis, hyperthyroidism, hypothyroidism, malignancy, infection, and pregnancy were excluded from the study. Mean age of the patients was 63 +/- 11 vs. 45 +/- 14 years (P < 0.001) in paroxysmal atrial fibrillation and control groups, respectively. Fifty-seven patients (55%) in paroxysmal atrial fibrillation and 19 (21%) (P < 0.001) patients in control group were men. Mean platelet volume was significantly higher in the paroxysmal atrial fibrillation group when compared with control group (10.0 +/- 2.0 vs. 8.3 +/- 1.5 fl, respectively; P < 0.001). C-reactive protein (18.5 +/- 28 vs. 3.8 +/- 2 mg/l, respectively; P = 0.004) and erythrocyte sedimentation rate (21 +/- 21 vs. 12 +/- 7 mm/h, respectively; P = 0.01) were also higher in the paroxysmal atrial fibrillation group. There was no difference in white blood cell and platelet counts between groups. In a multivariate analysis, elevated mean platelet volume was associated with the occurrence of paroxysmal atrial fibrillation before and after adjustment for age and sex. Our results indicate that inflammatory markers such as C-reactive protein and erythrocyte sedimentation rate and the marker of platelet size and activity mean platelet volume are elevated in patients with paroxysmal atrial fibrillation.

Value of preoperative echocardiography in the prediction of postoperative atrial fibrillation following isolated coronary artery bypass grafting.

The value of echocardiography, especially tissue Doppler imaging (TDI), in the assessment of risk of postoperative atrial fibrillation (AF) after coronary artery bypass grafting (CABG) is not clear. One hundred two consecutive patients (80 men; mean age 61 +/- 10 years) who underwent elective isolated CABG were included in the study. All patients underwent conventional transthoracic echocardiography and TDI of the left and right heart before surgery. Also, 24-hour Holter recordings were obtained for all patients. The study end point was the development of postoperative AF. The surgical mortality rate was 2%. Postoperative AF occurred in 18 patients (18%). Patients with postoperative AF have been significantly older than patients without postoperative AF (73 +/- 7 vs 58 +/- 9 years, respectively; p <0.001). Compared with patients without postoperative AF, a significantly higher proportion of patients with postoperative AF experienced paroxysmal AF before surgery (6% vs 33%, respectively; p = 0.001). Patients with postoperative AF had a significantly larger mean left atrial diameter compared with patients without postoperative AF (37 +/- 3 vs 35 +/- 3 mm, respectively; p = 0.012). Multivariate logistic regression analysis identified age as the most significant predictor of postoperative AF (odds ratio 1.254, 95% confidence interval 1.127 to 1.396; p <0.001). Of the echocardiographic variables, only left atrial diameter was identified as a significant predictor of postoperative AF (odds ratio 1.250, 95% confidence interval 1.055 to 1.562; p = 0.047). In conclusion, in the prediction of postoperative AF after isolated CABG, preoperative transthoracic echocardiography, including both conventional echocardiography and TDI, is of little value.

Retrograde pedal access with a 20-gauge intravenous cannula after failed antegrade recanalization of a tibialis anterior artery in a diabetic patient: a case report.

Retrograde tibiopedal approach is being used frequently in below-the-knee vascular interventions. In patients with diabetic foot pathology, complex anatomy often requires a retrograde technique when the distal vascular anatomy and puncture site is suitable. The dorsalis pedis and posterior tibial arteries can be punctured because of their relatively superficial position. We report a retrograde puncturing technique in patients with chronic total occlusions. After failed antegrade recanalization, puncturing and cannulation of a tiny dorsalis pedis artery with a narrow bore [20-gauge (0.8 mm)] intravenous cannula is described.