Diabetes mellitus and female gender are the strongest predictors of poor collateral vessel development in patients with severe coronary artery stenosis.

BACKGROUND: Coronary collateral vessel development (CVD), i.e., arteriogenesis, is regarded as one of the most important mechanisms­along with angiogenesis­to result in protection of the myocardium. Coronary CVD is associated with a reduction in infarct size, future cardiovascular events and improved survival in patients with occlusive coronary artery disease by enhancing regional perfusion in the chronically ischemic myocardium. In the present study, we aimed to investigate the relation of cardiovascular risk factors and hematological parameters with collateral development in patients with severely stenotic (≥95%) and totally occluded coronary artery disease including at least one major coronary artery. MATERIALS AND METHODS: The study population was selected from the patients who underwent coronary angiography between January 2008 and March 2009. Five hundred and two patients who had at least one coronary artery stenosis ≥95% (368 men; mean age 59 ± 10 years) comprised the study population. Of the 502 patients, 228 had total occlusion in at least one major epicardial coronary artery. Collateral artery grading was performed by using Cohen-Rentrop method to the vessel with coronary artery stenosis of ≥95% and patients with chronic total occlusions (CTO). Patients with grade 0-1 collateral development were regarded as the poor collateral group, and patients with grade 2-3 collateral development were regarded as the good collateral group. RESULTS: Two hundred and fifty-eight (51%) of 502 patients had poor collateral development, and 244 (49%) had good collateral development. Logistic regression analysis revealed that DM was independently associated with poor CVD in patients with ≥95% stenosis (p < 0.001). Additionally, female gender and DM were found to be independently associated with poor CVD in patients with CTO (p = 0.005 and p < 0.001, respectively). Monocyte count was found to be independent of CVD neither in patients with ≥95% stenosis nor in patients with CTO. CONCLUSION: Our data show that DM is an independent factor for poor coronary CVD both in patients with severe coronary artery stenosis and in patients with CTO. Female gender or being in post-menopausal period is another negative risk factor for poor CVD in addition to DM in patients with CTO.

Statins decrease mean platelet volume irrespective of cholesterol lowering effect.

BACKGROUND: Recent clinical observations have demonstrated that the beneficial effects of statins are not limited to LDL lowering effect. They have also favourable effects on platelet activation, endothelial function, inflammation, and coagulation cascade. AIM: To investigate the effects of statins on mean platelet volume (MPV) which is a simple measure of platelet activation volume in patients who have been prescribed statins. Atorvastatin and rosuvastatin were also compared in respect to effects on MPV. METHODS: One hundred and forty five patients were retrospectively included in the study from the outpatient cardiology clinic. Patients who had been given statin treatment were recruited based on the records. Baseline and 4-8 weeks biochemical analysis and haematological measurements and cardiovascular risk factors were recorded. RESULTS: Both statins significantly decreased the MPV. MPV of patients did not show any significant correlation with lipid parameters. Linear regression analysis revealed that there were no statistically significant associations of ∆ MPV with the ∆LDL-cholesterol (beta coefficient = 0.13; p = 0.24), ∆DL-cholesterol (beta coefficient = 0.17; p = 0.18) or ∆triglyceride (beta coefficient = -0.11; p = 0.21) after statin treatment. Both statins had comparable effects on lipid parameters at the end of the one month follow up period. CONCLUSION: Statins significantly reduce MPV irrespective of cholesterol levels, and atorvastatin and rosuvastatin have comparable effects in this regard.

Absence of posterior mitral leaflet with secundum atrial septal defect.

A rare case of a 54-year-old woman with absence of congenital posterior mitral leaflet, moderate mitral insufficiency, and large secundum-type atrial septal defect is reported. Two-dimensional color Doppler and transesophageal echocardiography revealed complete absence of the posterior mitral leaflet, a thick muscular formation replacing the posterior leaflet, a 3.3-cm secundum type atrial septal defect, and severe pulmonary hypertension. This report describes the rare case of congenital absence of posterior mitral leaflet associated with secundum type large atrial septal defect in a middle-age woman.

Cardiac findings in Behçet's patients.

Behçet's disease is a chronic multi-system inflammatory disorder and the severity and clinical manifestations of Behçet's patients may show geographic variation. We aimed to detect the cardiac findings in 30 Behçet's patients and compare them with the normal population (n = 29). We used color-doppler echocardiography and transesophageal echocardiography in combination. We calculated manually QT intervals and QT dispersion (QTd) from twelve-lead ECG recordings. There was no E/A inversion and coronary ischemia in all patients or control group. The E velocity difference between groups was not significant. The mean A velocity was significantly lower in Behçet's patients than normal group. The mean DT was 154.4 +/- 5.8 msec in Behçet's patients and 122.59 +/- 0.96 msec in control group (P < 0.0001). The mean IVRT was 75.66 +/- 1.36 msec in Behçet's patients and 69.1 +/- 0.55 msec in control group (P < 0.0001). There was no QTc time difference between the Behçet's patients and the control group. The mean QT dispersion (QTd) interval was 45.46 +/- 2.65 msec in Behçet's patients and 31.83 +/- 1.23 msec in control group (P < 0.0001). Atrial septal aneurysm, mitral valve prolapse and insufficiency, tricuspid valve insufficieny, and pulmonary hypertension frequencies in Behçet's patients were significantly higher than in the control group. We concluded that Behçet's cardiac involvement may effect cardiac structure and cause diastolic dysfunction, electrical instability and structural abnormalities. We also concluded that cardiac involvement in Behçet's disease may be specific for this geographic area.

Plasma viscosity and mean platelet volume in patients undergoing coronary angiography.

BACKGROUND: Markers of platelet activation and haemorrheological indices have been demonstrated to play a role in the pathophysiology of atherosclerosis and cardiovascular events. In this study, we aimed at investigate the association between plasma viscosity and platelet indices in patients undergoing coronary angiography. MATERIALS AND METHODS: Three hundred and eighty four consecutive patients scheduled to undergo coronary angiography were included in the study. Prior to coronary angiography, blood samples were withdrawn to determine routine biochemical markers, blood cell analyses and viscosity measurements. According to the results of coronary angiography, patients were classified either in a subgroup with coronary artery disease (CAD; 1 or more stenoses >50%) or normal coronary arteries (NCA; no stenoses or <50%). RESULTS: There was a statistically significant correlation between plasma viscosity and mean platelet volume levels in all patients undergoing coronary angiography (r=0.199, p<0.001). Additionally, when correlation analysis was performed within each group, plasma viscosity significantly correlated with MPV both in patients with CAD (r=0.18, p=0.004) and in patients with NCAs (r=0.272, p=0.002). Linear regression analysis revealed that plasma viscosity was positively associated with MPV while platelet number was inversely but significantly associated with MPV. CONCLUSION: We have shown for the first time that MPV correlates with plasma viscosity in patients undergoing coronary angiography, suggesting a relation with plasma proteins and activation of circulating platelets or peripheral consumption of platelets. To evaluate this relation further controlled studies also in patients with acute coronary syndromes are warranted.

Imaging of coronary artery anomalies: the role of multidetector computed tomography.

BACKGROUND: Coronary artery anomalies are evaluated by using catheter-based angiography. Multidetector row-computed tomography (MDCT) is a new noninvasive imaging technique that has excellent spatial resolution for detecting the origin and course of a coronary anomalous vessel. OBJECTIVE: To determine the sensitivity of multidetector computed tomography in patients who had coronary artery anomaly demonstrated by conventional coronary angiography. MATERIAL AND METHODS: A retrospective evaluation to identify 23 patients, who underwent retrospective electrocardiographic (ECG)-gated MDCT, was done and in whom an anomalous coronary vessel was found at a single center. Metoprolol (50-100 mg) was given orally to all patients to reduce heart rate so as to get high-quality MDCT images. After performing MDCT, the CT scans of each patient were analysed and compared with their coronary angiograms by two experienced radiologists and one cardiologist who were unaware about the study, and the sensitivity of MDCT was determined. RESULTS: Twenty-three patients (age range 28-73) with seven different coronary arteries of the anomalous type were evaluated. Nineteen patients had an anomalous left coronary artery; three patients had an anomalous single coronary artery; and one patient had an anomalous right coronary artery. The most common anomaly type was the left circumflex coronary artery (52%). The origin and course of all anomalous vessels were detected by ECG-gated MDCT (Lightspeed 16, GE Medical Systems, Milwaukee, Wisconsin, USA). The sensitivity of 100% of MDCT was detected in patients who had anomalous coronary vessels. CONCLUSION: We suggest that MDCT could be a non-invasive alternative imaging technique to conventional coronary angiography for screening the anomalous vessels of coronary arteries because of its excellent spatial resolution, which is very important for detecting the relationship of anomalous vessels with great arteries and cardiac structures.

Imaging of coronary artery fistulas by multidetector computed tomography: is multidetector computed tomography sensitive?

BACKGROUND: Coronary angiography is the gold standard for diagnosing coronary artery fistulas (CAFs). Multidetector computed tomography (MDCT) is a recently developed imaging technique for detecting coronary artery stenosis, coronary artery anomalies, and coronary artery fistulas and their courses. OBJECTIVE: We aimed to determine accuracy or sensitivity of MDCT in patients having CAF. METHOD: We evaluated 13 patients with 15 CAFs detected earlier by coronary angiography. MDCT was carried out on all patients and the results were compared with coronary angiography, following which, sensitivity of MDCT was detected. RESULTS: Eleven of 15 CAFs were shown on MDCT and the overall sensitivity of MDCT was found to be 73%. Seven of 8 CAFs that coursed between two vascular structures were detected and the sensitivity of MDCT in this group was found to be 87%. However, the sensitivity of 58% of MDCT in patients with fistula coursing between coronary arteries and cardiac chambers was found. CONCLUSION: Although coronary angiography is the gold standard diagnostic test for detection of CAF, MDCT may be an alternative test, especially, for CAF coursing between vascular structures, to detect origin, course, and the drainage site of fistula through its excellent spatial resolution and ability to show relationship of anatomic structures.

Single coronary artery presenting with cardiogenic shock due to acute myocardial infarction.

Percutaneous coronary revascularization plays an important role in the management of acute coronary syndrome. Unpredictable angiographic findings of anomalous coronary arteries may, however, compromise the otherwise high and predictable success rates of this intervention. We report a case of failed coronary angioplasty of the left anterior descending artery through an anomalous left main coronary artery originating from the right coronary sinus in a 33-year-old man with acute myocardial infarction complicated by cardiogenic shock. Subsequently the patient performed successful emergency coronary artery bypass graft.

A pericardial hydatid cyst masquerading as acute inferolateral myocardial infarction--a case report.

A case of pericardial hydatid cyst adjacent to the inferoposterial wall of the left ventricle is reported. Significant ST segment elevations in leads D2, D3, aVF, V5, and V6 on surface electrocardiography and sudden onset of severe chest pain mimicked acute inferolateral myocardial infarction. However, cardiac catheterization and coronary angiography showed normal coronary arteries and normal left ventricular cavity. The ST segment elevation in the inferolateral leads disappeared a few days after surgical resection of the cyst. Cardiac hydatid cyst should be considered in the differential diagnosis of patients with angina-like chest pain in endemic areas.

Elevated level of plasma homocysteine in patients with slow coronary flow.

BACKGROUND: Elevated plasma levels of homocysteine are currently considered a major, independent risk factor for cardiovascular diseases. Recently, several investigators have suggested that even mild elevation in plasma homocysteine level can severely disturb vascular endothelial function and subsequently impair coronary blood flow. Accordingly, we investigated plasma homocysteine level in patients with slow coronary flow. METHOD: Study population included 53 patients with angiographically proven normal coronary arteries and slow coronary flow in all three coronary vessels (group I, 21 females, 32 males, mean age=48+/-9 years), and 50 subjects with angiographically proven normal coronary arteries without associated slow coronary flow (group II, 22 females, 28 males, mean age=50+/-8 years). Coronary flow rates of all patients and control subjects were documented by Thrombolysis In Myocardial Infarction frame count (TIMI frame count). All patients in group I had TIMI frame counts greater than two standard deviations above those of control subjects (group II) and, therefore, were accepted as exhibiting slow coronary flow. The mean TIMI frame count for each patient and control subject was calculated by adding the TIMI frame counts for each major epicardial coronary artery and then dividing the obtained value into 3. Plasma homocysteine level was measured in all patients and control subjects using commercially available homocysteine kits. RESULTS: There was no statistically significant difference between two groups in respect to age, gender, hypertension, diabetes mellitus, hyperlipidemia and cigarette smoking (p>0.05). Plasma homocysteine level of patients with slow coronary flow were found to be significantly higher than those of control subjects (15.5+/-5.7 vs. 8.7+/-4.2 microM/l, respectively, p<0.001). Moreover, we found a significant positive correlation between plasma homocysteine level and mean TIMI frame count (r=0.660, p<0.001). CONCLUSION: We have shown that patients with slow coronary flow have raised level of plasma homocysteine compared to control subjects with normal coronary flow. This data suggests that elevated level of plasma homocysteine may play a role in the pathogenesis of slow coronary flow.

Increased thrombolysis in myocardial infarction frame count in patients with myocardial infarction and normal coronary arteriogram: a possible link between slow coronary flow and myocardial infarction.

BACKGROUND: Thrombolysis in myocardial infarction (TIMI) frame count is a simple clinical tool for assessing quantitative indexes of coronary blood flow. This technique counts the number of cineangiographic frames from initial contrast opacification of the proximal coronary artery to opacification of distal arterial landmarks. We hypothesized that patients with normal coronary artery (NCA) and myocardial infarction (MI) might have impaired coronary flow. Accordingly, we assessed the TIMI frame counts of patients with NCA and MI and compared to patients with NCA and without MI. MATERIALS AND METHOD: This retrospective study included consecutive patients with MI and who were found to have normal coronary angiograms performed between 1999 and 2003. Fifty patients (group I) with NCA and MI were enrolled in the study. Fifty consecutive patients with NCA and without MI were also enrolled in the study as control group (group II). Mean time interval between MI and coronary angiography was 6 +/- 2 days. RESULTS: There were statistically significant differences between groups I and II in respect to gender (11 females (22%) versus 22 females (44%), p = 0.003, respectively) and smoking status (62% (31/50) versus 38% (19/50), p = 0.02). Comparison of TIMI frame counts between two groups revealed that group I patients had significantly higher TIMI frame counts than group two patients for all three coronary arteries (LAD: 40 +/- 12 versus 23 +/- 7, Cx: 47 +/- 14 versus 27 +/- 7, RCA: 36 +/- 10 versus 26 +/- 10, respectively, p < 0.001 for all). Smokers were significantly younger when compared to non-smokers (44 +/- 5 years versus 51 +/- 9 years, p = 0.008, respectively). TIMI frame counts of smokers did not significantly differ from those of non-smokers in group I patients. There were statistically significant differences between smokers and non-smokers in group II patients regarding TIMI frame counts for all three coronary arteries (LAD: 29 +/- 7 versus 18 +/- 3, LCX: 34 +/- 10 versus 22 +/- 4, RCA: 34+ /- 13 versus 20 +/- 4, respectively, p < 0.001 for all). CONCLUSION: We have shown that patients with MI and NCA have higher TIMI frame counts for all coronary arteries when compared to patients without MI and NCA. Absence of difference between smokers and non-smoker in the myocardial infarction group in respect to TIMI frame count, has suggested that smoking does not lead to further increase of TIMI frame counts. On the other hand, in patients without MI and with NCA, smokers have higher TIMI frame counts than non-smokers have.

Effects of long-term beta-blocker therapy on P-wave duration and dispersion in patients with rheumatic mitral stenosis.

BACKGROUND: P-wave dispersion (PWD), has been defined as the difference between maximum and minimum P-wave duration. Prolonged P-wave duration and increased PWD have been reported to be related with increased risk for atrial fibrillation (AF). AF is the most common sustained arrhythmia encountered in patients with rheumatic mitral stenosis (MS). Beta-blockers are the mainstay of therapy in patients with rheumatic MS to control ventricular rate both during sinus rhythm and AF. In the present study, we aimed to evaluate the effect of long-term beta-blocker therapy on P-wave duration and PWD in patients with rheumatic MS. METHOD: Study population includes 46 patients (group I, 8 men, 38 women, mean age = 34+/-8 years) with newly diagnosed moderate-to-severe rheumatic MS who have not taken any medication before and prescribed oral beta-blocker therapy and 46 healthy control subjects without any cardiovascular disease (group II, 8 men, 38 women, mean age = 35+/-7 years). Mitral valve area, maximum and mean diastolic mitral gradients, left atrial diameter, and systolic pulmonary artery pressure were evaluated by transthoracic echocardiography before initiation of beta blocker therapy and repeated at the end of the first month. Baseline maximum and minimum P-wave duration and PWD were determined on 12-lead electrocardiogram recorded for each patient and control subject and repeated at the end of the first month after initiation of beta-blocker therapy in patient group. RESULTS: Maximum P-wave duration and PWD were found to be significantly higher in patients with MS than those in control subjects (Maximum P-wave duration: 128+/-7 ms vs. 104+/-4 ms and PWD: 52+/-6 ms vs. 27+/-3 ms, p < 0.001 for both). Both groups had comparable minimum P-wave duration (75+/-4 ms vs. 76+/-4 ms, p = 0.093). Maximum P-wave duration and PWD were found to be significantly decreased by long-term beta blocker therapy (Maximum P-wave duration; 128+/-7 ms vs. 122+/-6 ms, p < 0.001, PWD; 52+/-6 ms vs. 47+/-5 ms, p < 0.001). However, there was no significant difference between the values of minimum P wave duration measured before and at the end of the first month of beta-blocker therapy (75+/-4 ms vs. 75+/-3 ms, p = 0.678). Statistically significant decrease were detected on maximum and mean mitral gradient and systolic pulmonary artery pressure and resting heart rate at the end of the first month of beta-blocker therapy. However, only the change in resting heart rate was found to be significantly correlated with the decrease in maximum P-wave duration and PWD (Maximum P-wave duration: r = 0.327, p = 0.026, PWD: r = 0.378, p = 0.01). CONCLUSION: We have shown for the first time that long-term beta-blocker therapy causes a significant decrease in maximum P-wave duration and PWD in patients with rheumatic MS.

Increased levels of soluble adhesion molecules E-selectin and P-selectin in patients with cardiac syndrome X.

The role of endothelial dysfunction and platelet activation in patients with cardiac syndrome X is controversial. The aim of this study was to investigate the plasma levels of circulating E- and P-selectin molecules in patients with syndrome X. The study included 21 patients with cardiac syndrome X (11 men and 10 women, mean age = 56 +/- 5 years) and 20 patients with significant coronary artery disease who had stable angina pectoris (11 men and 9 women, mean age = 60 +/- 8 years). Twenty-two age- and sex-matched subjects (12 men and 10 women, mean age = 58 +/- 8 years) undergoing diagnosis of atypical chest pain in whom coronary arteries were found normal and exercise test had no signs of ischemia served as the control group. Syndrome X was defined as presence of typical chest pain on exertion or at rest with positive exercise test and angiographically normal epicardial coronary arteries with no evidence of coronary spasm after intracoronary infusion of ergonovine maleate. The mean plasma concentrations of P-selectin were significantly elevated both in patients with coronary artery disease and syndrome X as compared with control subjects (49.15 +/-7.47 and 42.80 +/- 8.93 vs 22.63 +/-6.47 ng/mL, p < 0.001). Similarly, both patients with coronary artery disease and syndrome X had higher plasma concentrations of E-selectin than the control group (78.85 +/- 16.69 and 68.38 +/- 15.30 vs 36.43 +/- 4.72 ng/mL, p < 0.001). In conclusion, patients with syndrome X had increased plasma concentrations of soluble adhesion molecules, E-selectin and P-selectin, reflecting an ongoing chronic inflammation involved with endothelial dysfunction and enhanced platelet activation/damage in this setting.

The role of valvular and thoracic aortic calcifications in distinction between ischemic and nonischemic cardiomyopathy.

Determination of underlying etiology in patients with dilated and globally hypokinetic left ventricles may sometimes be difficult even after detailed history and complete clinical evaluation. Cardiac valvular and thoracic aortic calcifications have previously been reported to be used as a window to diffuse atherosclerosis of the vascular system. The authors prospectively examined the predictive value of mitral annular calcification (MAC), aortic valve calcification (AVC), and thoracic aortic calcification (TAC) in diagnosis of coronary artery disease as the underlying cause of diffuse left ventricular dilatation and systolic dysfunction. The study included 98 consecutive patients (male/female = 76/22, mean age = 58.9 +/- 10.7 years, range: 33 to 75 years) over the age of 30 years admitted to their clinics between October 1999 and December 2001 with signs and symptoms of congestive heart failure associated with documented cardiomegaly. Transthoracic echocardiography and coronary angiography were performed in all patients for the evaluation of valvular calcifications and coronary status. Although there was no significant difference between the groups with and without coronary artery stenosis (CAS), with regard to presence of MAC, patients with CAS tended to have MAC more frequently (12/61, 20% vs 4/37, 11%, p > 0.05). AVC and TAC were found to be significantly more frequent in patients with CAS compared to those without CAS (AVC, 35/61, 57% vs 4/37, 11%, p < 0.001 and TAC, 28/61, 46% vs 2/37, 5%, p < 0.001). While all 3 calcifications had sensitivity under 60%, and specificity and positive predictive value over 75% individually, the presence of any of them had a sensitivity of 80%, specificity of 86%, positive predictive value of 91%, and negative predictive value of 73%. Thus the presence of any of these calcifications distinguished patients with coronary artery disease with a sensitivity of 80% and specificity of 86%. The presence of aortic valvular valve and thoracic aortic calcifications seems to be associated with significant coronary arterial stenosis; however, with relatively low negative predictive values these cannot be used in clinical practice for diagnosis of underlying coronary artery disease in patients with dilated left ventricles and impaired systolic functions.