Usefulness of the SYNTAX Score II to Predict In-Hospital and Long-Term Mortality in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention.

Objectives: The prognostic significance of SYNTAX Score II (SS-II) is well-known in patients with chronic coronary syndromes. However, its predictive ability for mortality in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (p-PCI) remains unclear. Therefore, we aimed to investigate the prognostic accuracy of SS-II in STEMI patients who underwent p-PCI. Methods: A total of 743 STEMI patients treated with p-PCI were retrospectively analyzed. Study population was divided into three groups according to SS-II and defined as SS-IILOW ≤22.5 (n=245), 22.5 31 (n=255). In-hospital and long-term mortality at long-term follow-up were defined as clinical endpoints of the study. Results: The incidence of in-hospital (15% vs. 0.4% vs. 0.8%, p<0.001) and all-cause mortality (32.2% vs. 6.6% vs. 2.9%, p<0.001) were significantly higher in SS-IIHIGH group compared with the other two groups. In addition, Kaplan-Meier analysis showed statistically significantly increased incidence of death in SS-II > 31 group (P [log-rank] <0.001). SS-II >31 was defined as an independent predictor of all-cause mortality (hazard ratio 5.22 95% confidence interval 2.11-12.87 p<0.001). Area under the curve values derived from ROC analysis to evaluate the predictive accuracy of SS-II, anatomical and clinical SS, modified ACEF score, and Global Registry of Acute Coronary Events risk scores for all-cause mortality were 0.82, 0.71, 0.81, 0.82, and 0.82, respectively (p<0.001). Conclusion: SS-II has an increased predictive ability for in-hospital and long-term mortality in STEMI patients undergoing p-PCI.

Long-Term Follow-Up of Patients With Isolated Side Branch Coronary Artery Disease.

The data with respect to stable coronary artery disease (SCAD) are mainly confined to main vessel disease. However, there is a lack of information and long-term outcomes regarding isolated side branch disease. This study aimed to evaluate long-term major adverse cardiac and cerebrovascular events (MACCEs) in patients with isolated side branch coronary artery disease (CAD). A total of 437 patients with isolated side branch SCAD were included. After a median follow-up of 38 months, the overall MACCE and all-cause mortality rates were 14.6% and 5.9%, respectively. Among angiographic features, 68.2% of patients had diagonal artery and 82.2% had ostial lesions. In 28.8% of patients, the vessel diameter was ≥2.75 mm. According to the American College of Cardiology lesion classification, 84.2% of patients had either class B or C lesions. Age, ostial lesions, glycated hemoglobin A1c, and neutrophil levels were independent predictors of MACCE. On the other hand, side branch location, vessel diameter, and lesion complexity did not affect outcomes. Clinical risk factors seem to have a greater impact on MACCE rather than lesion morphology. Therefore, the treatment of clinical risk factors is of paramount importance in these patients.

Incidence of atrial fibrillation and its effects on long-term follow-up outcomes in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction.

OBJECTIVE: The incidence of atrial fibrillation (AF) in patients with ST segment elevation myocardial infarction (STEMI) varies between 7% and 21%, and most of these studies were in the thrombolytic era. However, the frequency of new-onset AF during the primary percutaneous coronary intervention (PCI) period is still unclear. We aimed to investigate the frequency of new-onset AF and its effects on long-term clinical events in patients undergoing primary PCI. METHODS: A total of 1,603 patients who were diagnosed with STEMI and underwent primary PCI were included in the study. All the patients were monitored for at least 48 hours after the procedure. The primary endpoint of the study was defined as new-onset AF during hospitalization. RESULTS: The median follow-up period of our study was 44 months. New-onset AF developed in 85 (6.1%) patients. CHADs-VASc > 2, KILLIP > 2, and left atrial diameter were found to be independent predictors for the development of new-onset AF. In the AF (+) group, the all-cause and in-hospital mortality rates were found to be significantly higher. New-onset AF development in patients with STEMI was detected as an independent predictor of in-hospital mortality. CONCLUSION: In the era of primary percutaneous transluminal coronary angioplasty, new-onset AF rates were found to be lower than the literature data. In addition, new-onset AF was found to be a predictor of in-hospital mortality, and deaths occurred mostly in the early period. Therefore, close follow-up of these patients in the early period and re-evaluation in terms of AF burden when the patient becomes stable are important.

Avoiding the emergence of contrast-induced acute kidney injury in acute coronary syndrome: routine hydration treatment.

BACKGROUND: Patients with acute coronary syndrome (ACS) have about a three-fold risk for developing contrast-induced acute kidney injury(CI-AKI). Investigating studies on routine hydration therapy have frequently included patients with stable coronary artery disease and high risk of CI-AKI [estimated glomerular filtration rate (eGFR) < 60 ml/min]. However, data on routine hydration treatment in non-ST segment elevation myocardial infarction (NSTEMI) patients with eGFR ≥60 ml/min are insufficient. We aimed to investigate the association between routine hydration therapy and CI-AKI development in NSTEMI patients at low risk for nephropathy. METHODS AND RESULTS: We randomly assigned a total of 401 NSTEMI patients to two groups: the routine hydration group (198 patients) and the nonhydration group (control group) (203 patients). Intravenous hydration with isotonic saline (1 ml/kg/h, 0.9% sodium chloride) was given for 3-12 h before and 24 h after contrast exposure to the hydration group. CI-AKI was defined as the increase in serum creatinine values 0.5 mg/dl or 25% between 48 and 72 h after the invasive procedures. In our study, the incidence of CI-AKI development in the routine hydration group (7.1%) was significantly lower than in the nonhydration group (14.1%) (P: 0.02). This study revealed that older age, amount of contrast media, and routine hydration were independent risk factors for developing CI-AKI (P < 0.01, P: 0.04, P < 0.01, respectively). CONCLUSION: We found that preprocedural and postprocedural intravenous hydration therapy reduces the development of CI-AKI in patients with NSTEMI at low risk for CI-AKI. We suggest administering routine hydration therapy in all ACS patients regardless of eGFR values.

The relationship between protein convertase subtilisin kexin type-9 levels and extent of coronary artery disease in patients with non-ST-elevation myocardial infarction.

BACKGROUND: Cardiovascular disease is one of the leading causes of death worldwide. According to the results of various studies, protein convertase subtilisin kexin type-9 (PCSK9) was determined as a novel risk factor for stable coronary artery disease. Few studies have investigated the relationship between PCSK9 levels and the severity of coronary artery disease in patients with acute coronary syndrome; thus, we herein aimed to investigate this relationship in patients with non-ST-elevation myocardial infarction (NSTEMI) who underwent coronary angiography. PATIENTS AND METHODS: Herein, 168 patients with NSTEMI were prospectively enrolled, and severity of atherosclerotic lesions was determined using SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX), Gensini and Jeopardy scores. Plasma PCSK9 levels, lipid parameters and C-reactive protein levels were measured after a 12-h fasting period. The relationship of PCSK9 levels and clinical and laboratory parameters of patients with their SYNTAX, Gensini and Jeopardy scores was investigated. RESULTS: Pearson correlation analysis showed a strong positive correlation between PCSK9 and the three scores (P < 0.001, r > 0.5 for all). In ROC analysis, a mid-high SYNTAX score of at least 25 was predicted with a sensitivity of 81% and a specificity of 63% when the PCSK9 level was higher than 52.8 ng/ml (area under a curve 0.76, P < 0.001). Multivariate linear regression analysis revealed that PCSK9, low-density lipoprotein cholesterol and creatinine levels were independent predictors of a high SYNTAX score. CONCLUSION: Taken together, high PCSK9 levels may be a risk factor for adverse events in patients with NSTEMI. Aggressive lipid-lowering therapies may benefit this group of patients.

Effects of ECE-1b rs213045 and rs2038089 polymorphisms on the development of contrast-induced acute kidney injury in patients with acute coronary syndrome.

OBJECTIVE: Endothelin-1 (ET-1) promotes the progression and induction of sclerotic renal changes in end-stage kidney disease. Membrane-bound endothelin-converting enzyme 1 (ECE-1) is involved in the production of ET-1. The aim of this study was to assess the effects of ECE-1b rs213045 and rs2038089 polymorphisms, which have been shown to be involved in the development of atherosclerosis, hypertension, and nephropathy, on the development of contrast-induced acute kidney injury (CI-AKI) in patients with acute coronary syndrome. METHODS: Our study included 38 patients with CI-AKI (CI-AKI[+]) and 55 patients without CI-AKI (CI-AKI[-]) who had coronary syndrome. The ECE-1b polymorphisms rs213045 and rs2038089 were assessed using real-time PCR. Serum ET-1 levels were measured by ELISA. RESULTS: The distributions of ECE-1b rs213045 and rs2038089 polymorphisms were similar between the two groups. Additionally, the serum ET-1 level did not different between the groups and was not associated with the ECE-1b polymorphisms. Peri-procedural low systolic blood pressure (SBP) was identified as a risk factor for CI-AKI development. CONCLUSION: Our findings indicate that ECE-1b rs213045 and rs2038089 polymorphisms are not associated with CI-AKI development and that peri-procedural low SBP is a risk factor for CI-AKI. However, variations in ECE-1b rs2038089 may contribute to the development of CI-AKI.

The association of neutrophil to lymphocyte ratio and TIMI frame count in primary percutaneous coronary intervention.

BACKGROUND: This study was sought to evaluate the relationship between admission neutrophil lymphocyte ratio (NLR) and estimated coronary flow by the TIMI frame count (TFC) method in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). METHODS: TFC of 262 consecutive STEMI patients were evaluated after PPCI. Admission NLR were calculated and TFC was determined after PPCI. According to admission NLR value, patients were divided in to two groups. NLR levels higher than 3.5 were defined "higher NLR" whereas lower than 3.5 were accepted as "lower NLR". RESULTS: TFC was significantly higher in patients with higher NLR (56.6±41.1 vs. 37.9±36.1, P<0.001). No-reflow phenomenon was more frequent in higher NLR group compared to lower NLR group (10.1% vs. 5.2%, P=0.001). In multivariate linear regression analysis admission NLR was an independent predictor of high TIMI frame count (B=2.24 95 % CI (1.17-3.31), P<0.001). CONCLUSIONS: Our findings suggest that admission NLR predicts coronary blood flow in means of TFC.

Comparative performance of AnTicoagulation and Risk factors In Atrial fibrillation and Global Registry of Acute Coronary Events risk scores in predicting long-term adverse events in patients with acute myocardial infarction.

OBJECTIVE: This study is designed to evaluate the recently developed AnTicoagulation and Risk factors In Atrial fibrillation (ATRIA) risk score (RS), which determines the predisposition to thromboembolic and hemorrhagic events in atrial fibrillation, as a predictor of prognosis in patients having acute myocardial infarction (AMI), and to compare the predictive ability of ATRIA RS with GRACE RS. METHODS: We analyzed 1627 patients having AMI who underwent coronary angiography and/or percutaneous coronary intervention (PCI) between January 2011 and February 2015. The primary endpoints included all-cause mortality, non-fatal MI, and cerebrovascular events during follow-up. RESULTS: Multivariate Cox regression analysis showed that the ATRIA RS>3 was an independent predictor of major adverse cardiac events in patients with AMI [hazard ratio, 2.00, 95% confidence interval, 1.54 to 2.60, p<0,001]. The area under the curve (AUC) for ATRIA RS and GRACE RS was 0.66 and 0.67 (p<0.001, and p<0.001), respectively. We performed a pair-wise comparison of receiver operating characteristic curves,and noted the predictive value of ATRIA RS with regard to primary endpoints was similar to that of GRACE RS (By DeLong method, AUCATRIA vs. AUCGRACE z test=0.64, p=0.52). CONCLUSION: ATRIA RS may be useful in predicting prognosis in patients having AMI during long-term follow-up.

Effect of chronic toluene exposure on heart rhythm parameters.

BACKGROUND: Toluene is used extensively in various industrial processes, and an increasing number of workers are getting exposed to its vapor. Cardiac abnormalities that have been reported in association with toluene exposure (in toxic doses) are atrioventricular conduction abnormalities, sinus bradycardia, ventricular tachycardia, recurrent myocardial infarction, dilated cardiomyopathy, and coronary vasospasm. HYPOTHESIS: We aimed to investigate the effects of chronic toluene exposure on cardiac rhythm. METHODS: In this study, 40 workers in the polishing industry with more than 3 months of exposure to a mixture of organic solvents including toluene and 38 control subjects working in other fields who were matched by age, sex, smoking, habits, and living accommodation were investigated. Twelve-lead surface electrocardiogram and 24-hour Holter recordings were performed to determine QRS duration, PR duration (P and R wave interval on electrocardiograms), P wave dispersion, corrected QT dispersion, and heart rate variability parameters. RESULTS: The maximum heart rate was significantly lower in the toluene-exposed group compared to the control group (130.5 ± 15.1 vs 138.6 ± 16.0, P = 0.02). Corrected low frequency (cLF) and cLF/corrected high frequency (cHF) were also significantly lower in toluene-exposed group (43.6 ± 7.2 vs 50.7 ± 10.5, P = 0.01 and 1.4 ± 0.4 vs 2.2 ± 1.0, P < 0.01, respectively). Mean cHF, root-mean-square successive difference, and standard deviation of all five-minute NN interval means values were significantly higher in the toluene-exposed group (32.8 ± 8.1 vs 25.4 ± 8.2, P ≤ 0.01; 74.0 ± 46.1 vs 60.3 ± 59.4, P = 0.02; and 149.5 ± 77.0 vs 108.9 ± 43.2, P = 0.01, respectively). CONCLUSIONS: This study implies that chronic toluene exposure disturbs cardiac autonomy, particularly by suppressing sympathetic activity, and parasympathetic suppression also occurs with increased exposure duration. We also demonstrated that chronic toluene exposure was not associated with major cardiac arrhythmias and rhythm conduction system disorders.

Contrast-Induced Acute Kidney Injury Is Associated With Long-Term Adverse Events in Patients With Acute Coronary syndrome.

Contrast-induced acute kidney injury (CI-AKI) is associated with increased mortality, morbidity, and prolonged hospitalization. Patients with acute coronary syndrome (ACS) have a 3-fold higher risk of developing CI-AKI. The aim of our study was to evaluate the predictors of CI-AKI and long-term prognosis in patients with ACS who developed CI-AKI (1083 patients were enrolled). Contrast-induced acute kidney injury was defined as an increase of ≥0.5 mg/dL and/or an increase of ≥25% of pre-percutaneous coronary intervention (PCI) to post-PCI serum creatinine levels within 48 to 72 hours after the procedure. Primary end point was defined as all-cause mortality, myocardial infarction, and cerebrovascular event at long-term follow-up (36 ± 12 months). Contrast-induced acute kidney injury occurred in 178 (16.4%) of the 1083 patients. The primary end points were significantly high in patients with ACS who developed CI-AKI ( P < .001). The occurrence of CI-AKI was identified as an independent predictor of primary end point. Risk of CI-AKI development was more frequently seen in patients with ACS. Also, patients who developed CI-AKI have worse prognosis at long-term follow-up. Additional preventive treatment strategies need to be developed in this group of patients.

Relationship between myocardial performance index and severity of coronary artery disease in patients with non-ST-segment elevation acute coronary syndrome.

OBJECTIVES: We aimed to investigate the relationship between myocardial performance index (MPI) and severity of coronary artery disease, as assessed by the Gensini score (GS), in patients with non-ST-segment elevation myocardial infarction (NSTEMI). METHODS: Ninety patients with an initial diagnosis of NSTEMI were enrolled in our study. They were divided into tertiles according to the GS: low GS < 19; mid GS > 19 and ≤ 96; and high GS > 96. RESULTS: The low-, mid- and high-GS groups included 24, 38 and 28 patients, respectively. Clinical features such as gender distribution; body mass index (BMI); prevalence of diabetes mellitus, hypertension and hyperlipidaemia; and smoking status were similar in the three groups. MPI and isovolumic relaxation time were significantly higher in the high-GS group than in the low- and mid-GS groups (p < 0.001 and p = 0.005, respectively). Furthermore, the high-GS group had a significantly lower ejection fraction and ejection time (p = 0.01 and p < 0.001, respectively). MPI was positively correlated with the GS (r = 0.47, p < 0.001), and multivariate regression analysis showed that MPI was an independent predictor of the GS (ß = 0.358, p < 0.001). CONCLUSIONS: Patients with NSTEMI who fall within the high-risk group may be identified by means of a simple MPI measurement.

The value of the Clinical SYNTAX Score in predicting long-term prognosis in patients with ST-segment elevation myocardial infarction who have undergone primary percutaneous coronary intervention.

BACKGROUND: The Clinical SYNTAX Score (CSS) combines anatomical and clinical risk assessment. OBJECTIVES: This study was designed to evaluate CSS as a predictor of prognosis in patients with ST-elevation myocardial infarction (STEMI) undergoing a primary percutaneous coronary intervention (p-PCI). METHODS: We evaluated 433 patients who were diagnosed with STEMI and underwent p-PCI. CSS was calculated by multiplying the anatomically derived SYNTAX score (Sx) by the modified age, creatinine, and ejection fraction score. Patients were divided into tertiles according to the CSS: CSS(Low)≤14 (n=141), 1426 (n=148). The primary endpoints were defined as all-cause mortality, myocardial infarction, and cerebrovascular events over 15 months' follow-up. RESULTS: Primary endpoints were achieved in 9.2% of patients with CSS≤14, 12.5% of those with 1426 (P<0.001). Kaplan-Meier analysis showed that the CSS>26 group had a significantly higher incidence of primary endpoints [P (log-rank)<0.001]. CSS>26 was identified as an independent predictor for all-cause mortality, myocardial infarction, and cerebrovascular events (hazard ratio 3.58, 95% confidence interval 1.68-7.60, P=0.001). Receiver operating characteristic analysis found areas under the curve of 0.66, 0.59, and 0.64 for CSS, Sx score, and age, creatinine, and ejection fraction score (P<0.001, P=0.01, P<0.001, respectively). CONCLUSION: CSS may be better than the Sx score for predicting long-term prognosis in patients with STEMI undergoing p-PCI.

Heart rate turbulence in patients with stable coronary artery disease and its relationship with the severity of the disease.

OBJECTIVE: Heart rate turbulence (HRT) indicates the impairment of cardiac autonomic function. With the literature containing insufficient information on HRT in stable coronary artery disease (CAD), this study aimed to investigate the role of HRT in patients with stable CAD. METHODS: The study included 58 patients (mean age: 58.9 ± 10.0 years; 25 male) with documented CAD and demonstrating ventricular premature complexes on Holter monitoring, and a control group of 52 patients (mean age: 55.9 ± 9.3 years; 36 male) with no history of CAD and demonstrating ventricular premature complexes. HRT parameters such as turbulence onset (TO) and slope (TS) were analyzed. Angiographic Gensini score were used to evaluate CAD severity. RESULTS: There was a significant difference in HRT parameters between the 2 groups. TO: 0.47 ± 1.52% vs. -1.61 ± 2.0% (p=0.001) and TS: 4.7 ± 3.0 vs. 6.4 ± 3.7 ms/RR (p=0.009) in patients with CAD and control group respectively. Given also that TO ≥ 0% and TS ≤ 2.5 ms/ RR values are considered abnormal, there was significant difference between the two groups; TO abnormal: 27 patients (46.6%) vs. 7 patients (13.5%), p=0.001, and TS abnormal: 15 patients (25.9%) vs. 4 patients (7.7%), (p=0.004) in CAD patients and control group respectively. A positive correlation was detected between TO and Gensini score (r=0.282, p=0.001) and a negative correlation detected between TS and Gensini score (r=-0.287, p=0.001). CONCLUSION: The study demonstrated that HRT variables are impaired in patients with stable CAD when compared to those in the control group, and that these variables also correlate with severity of CAD.

Platelet-to-Lymphocyte Ratio Predicts Contrast-Induced Nephropathy in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome.

We assessed the relation between platelet-to-lymphocyte ratio (PLR) on admission and contrast-induced nephropathy (CIN) in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). A total of 488 patients with NSTE-ACS who underwent urgent coronary angiography were enrolled. Levels of PLR and creatinine were measured before angiography and at 72 hours after angiography. Patients were divided into 2 groups, namely, the CIN group, 80 patients (16.3%; age 65.3 ± 12.5years; 66.7% men) and the non-CIN group, 408 patients (83.7%; age 61.2 ± 12.3 years; 72.5% men). Patients in the CIN group had significantly higher PLR than those in the non-CIN group (152.9 ± 99.6 vs 120.4 ± 66.1, P < .001). In logistic regression analysis, PLR (odds ratio [OR] 1.004, 95% confidence interval [CI] 1.001-1.007, P = .02), diabetes mellitus (OR 1.75, 95% CI 1.02-2.98, P = .03), and ST-segment depression on admission electrocardiogram (OR 1.68, 95% CI 1.00-2.81, P = .04) were independent predictors of CIN. The PLR was an independent predictor of CIN after angiography in patients with NSTE-ACS.