Unilateral common carotid artery dissection in a patient with recent COVID-19: An association or a coincidence?

The "Corona Virus Disease 2019 (COVID-19)", caused by severe acute respiratory coronavirus 2 (SARS-CoV-2), progressed rapidly since its first outbreak, and quickly developed into a pandemic. Although COVID-19 mostly presents with respiratory symptoms, researchers have started reporting neurologic manifestations such as cerebrovascular diseases in patients, with COVID-19 as the pandemic has progressed. Herein, we report a case of 38-year-old female patient identified with a left common carotid artery dissection, with COVID-19. Clinicians must keep in mind that COVID-19 can cause vascular complications such as carotid artery dissections in the ensuing period, even after the acute phase, although there is currently a lack of sufficient evidence to identify any causal association between COVID-19 and arterial dissections.

Plasma osmolality predicts mortality in patients with heart failure with reduced ejection fraction.

BACKGROUND: Heart failure (HF) is a fatal disease. Plasma osmolality with individual impacts of sodium, blood urea nitrogen (BUN), and glucose has not been studied prognostically in patients with HF. AIM: This study aims to investigate the impact of serum osmolality on clinical endpoints in HF patients. METHODS: A total of 509 patients (383 males, 126 females) with HF with reduced ejection fraction in three HF centres were retrospectively analysed between January 2007 and December 2013. Follow-up data were completed for 496 patients. Plasma osmolality was calculated as (2 × Na) + (BUN/2.8) + (Glucose/18). Quartiles of plasma osmolality were produced, and the possible relationship between plasma osmolality and cardiovascular mortality was investigated. RESULTS: The mean follow-up was 25 ± 22 months. The mean age was 56.5 ± 17.3 years with a mean EF of 26 ± 8%. The mean levels of plasma osmolality were as follows in the quartiles: 1st % = 280 ± 6, 2nd % = 288 ± 1, 3rd % = 293 ± 2 (95% confidence interval [CI] 292.72-293.3), and 4th % = 301 ± 5 mOsm/kg. The EF and B-type natriuretic peptide levels were similar in the four quartiles. Univariate and multivariate analyses in the Cox proportional hazard model revealed a significantly higher rate of mortality in the patients with hypo-osmolality. The Kaplan-Meier plot showed graded mortality curves with the 1st quartile having the worst prognosis, followed by the 4th quartile and the 2nd quartile, while the 3rd quartile was shown to have the best prognosis. CONCLUSIONS: Our study results suggest that normal plasma osmolality is between 275 and 295 mOsm/kg. However, being close to the upper limit of normal range (292-293 mOsm/kg) seems to be the optimal plasma osmolality level in terms of cardiovascular prognosis in patients with HF.

Relationship between functional capacity and socioeconomic status in a cohort of Turkish heart failure patients.

OBJECTIVE: New York Heart Association (NYHA) classification predicts prognosis for heart failure (HF) patients. Socioeconomic status (SES) has the potential to affect treatment strategy and disease course. The present objective was to investigate whether SES of Turkish HF patients affected NYHA classification. METHODS: Turkish research team-HF (TREAT-HF) is a questionnaire study with 52 questions, the purpose of which is to aid in the assessment of various qualities of HF patients. The 2013 TREAT-HF cohort included 503 patients from 11 centers in Turkey. Patients were divided into 2 groups according to NYHA functional classification: I-II, a better functional classification, or III-IV, a poorer functional classification. In addition, patients were analyzed according to gender. RESULTS: Evaluated were NYHA functional classifications of 459 (326 males and 133 females) patients with a mean age of 59.7±14.07 years and a mean ejection fraction (EF) of 31.7±9.22%. Total monthly family income level of ≥1000 TL, younger age, higher EF, and male gender were independently associated with better NYHA functional classification. In addition to EF, regular weight control was found to be independently associated with better NYHA classification for females, while younger age and income of ≥1000 TL were independently associated with better NYHA classification for males. CONCLUSION: The present results demonstrated that SES was associated with NYHA functional classification in a cohort of Turkish HF patients.

Lymphocytopenia is associated with poor NYHA functional class in chronic heart failure patients with reduced ejection fraction.

OBJECTIVE: In heart failure (HF) patients, functional capacity has been demonstrated to be a marker of poor prognosis, independent of left ventricular ejection fraction (EF). Lymphocyte count is currently recognized in certain risk stratification scores for chronic HF, and severe HF is associated with lymphocytopenia. However, no data exists on the association between lymphocyte count and functional capacity in patients with stable HF. This study aimed to assess the relationship between lymphocyte count and New York Heart Association (NYHA) functional capacity in systolic HF outpatients. METHODS: The Turkish Research Team-HF (TREAT-HF) is a network which undertakes multi-center observational studies in HF. Data on 392 HF reduced ejection fraction (HFREF) patients from 8 HF centers are presented here. The patients were divided into two groups and compared: Group 1 comprised stable HFREF patients with mild symptoms (NYHA Class I-II), while Group 2 consisted of patients with NYHA Class III-IV symptoms. RESULTS: Patient mean age was 60±14 years. Lymphocyte count was lower in patients with NYHA functional classes III and IV than in patients with NYHA functional classes I and II, (0.9 [0.6-1.5]x1000 versus 1.5 [0.7-2.2]x1000, p<0.001). In multivariate logistic regression analysis, lymphocyte count (OR: 0.602, 95% CI: 0.375-0.967, p=0.036), advanced age, male gender, presence of hypertension, EF, left atrium size, systolic pulmonary artery pressure, neutrophil and basophil counts, creatinine level, and diuretic usage were associated with poor NYHA functional class in systolic HF outpatients. CONCLUSION: The present study demonstrated that in stable HFREF outpatients, lymphocytopenia was strongly associated with poor NYHA function, independent of coronary heart disease risk factors.

Factors influencing the use of ambulance among patients with acute coronary syndrome: results of two centers in Turkey.

OBJECTIVE: In this study, we aimed to identify the factors influencing the use of ambulance among patients admitted to two Turkish hospitals with acute coronary syndrome (ACS). METHODS: Overall, 330 with a mean age of 55±13 years, hospitalized patients with ACS at 2 different hospitals were included in this prospective cohort study. The factors influencing the use of ambulance hospital were investigated through a questionnaire. The comparisons were made between two groups regarding use of ambulance. The predictors of the use of ambulance were determined using multiple logistic regression analysis. RESULTS: Despite the high rate of knowing the emergency service number of "112", of the 330 patents, only 96 (29%) used ambulance. Ambulance users had shorter arrival duration with median of 60 min vs 120 min (p=0.03). Presenting with ST elevation myocardial infarction (OR=3.127, 95% CI: 1.555-6.2877, p<0.001), severity of chest pain (OR=2.665, 95% CI: 1.938-3.665, p<0.001), presence of accompanying symptoms such as dyspnea (OR= 5.510, 95% CI: 2.614-11.614, p<0.001), dizziness (OR=4.172, 95% CI: 1.901-9.154, p<0.001) and vomiting (OR=3.756, 95% CI: 1.521-9.272, p=0.004), knowledge of cardiac risk factors (OR=10.512, 95% CI: 4.497-24.572, p<0.001) or chest pain related to heart attack and the importance of quickly seeking for medical care by calling ambulance (OR= 4.184, 95% CI: 2.528-6.926, p<0.001) are the factors associated with ambulance use. CONCLUSION: Using ambulance was in a very low rate among our study patients with ACS. Severity of symptoms, type of ACS and knowledge are seemed to be related with increased ambulance use. Informative health educational programs can be organized to achieve a behavioral change in using of ambulance.

Sonographic evaluation for predicting the presence and severity of coronary artery disease.

PURPOSE: The aim of our study was to investigate the relationship between age, sex, obesity, nonalcoholic fatty liver disease (NAFLD), carotid intima-media thickness (CIMT), and both the presence and severity of coronary artery disease (CAD) and their predictive value for the presence and severity of CAD. METHODS: Our study population consisted of 136 patients who underwent coronary angiography for various reasons. Gensini scoring was used to determine the severity of coronary atherosclerosis. Carotid intima-media thickness was estimated by carotid duplex ultrasound. Nonalcoholic fatty liver disease was diagnosed by abdominal ultrasonography. Body mass index (BMI) was calculated as kilograms divided by meters squared. RESULTS: Coronary artery disease was detected in 74 patients (54%). In the whole group, patients with CAD had significantly higher CIMT measurements compared with those without CAD (0.93 [SD, 0.14] and 0.72 [SD, 0.12] mm, respectively, P < 0.001). Carotid intima-media thickness was correlated with BMI (P < 0.001, r = 0.453), age (P = 0.001, r = 0.389), and grade 2-3 NAFLD (P < 0.001, r = 0.356). In the multiple logistic regression model, CIMT (odds ratio, 1.189; 95% confidence interval, 1.122-1.261; P < 0.001) was the only independent predictor of the presence of CAD. In receiver operating characteristic curve analysis, optimal cutoff value of CIMT to predict the presence of CAD was found as greater than 0.75 mm with 93.2% sensitivity and 71% specificity. In CAD group patients, Gensini score was correlated with CIMT (P < 0.001, r = 0.604), grade 2-3 NAFLD (P < 0.001, r = 0.534), BMI (P < 0.001, r = 0.498), and age (P = 0.001, r = 0.385). In the multiple stepwise linear regression model, CIMT (ß = 0.444, P < 0.001) and grade 2-3 NAFLD (ß = 0.353, P < 0.001) were associated with severity of CAD. CONCLUSIONS: Our data suggest that CIMT is a strong independent predictor for the presence and severity of CAD. Furthermore, moderate to severe hepatosteatosis is also significantly associated with the severity of CAD. Therefore, detection of CIMT and NAFLD by ultrasonography, which is a very cheap, safe, and noninvasive radiological modality, can be used to improve CAD risk prediction.

Advanced age and apnea-hypopnea index predict subclinical atherosclerosis in patients with obstructive sleep apnea syndrome.

BACKGROUND: Both obstructive sleep apnea syndrome (OSAS) and coronary artery calcification (CAC) are considered to be related with the presence of coronary artery disease (CAD). In this study we evaluate the association between OSAS and presence of subclinical atherosclerosis assessed by tomographic coronary calcium score in patients who had OSAS but no history of known CAD. METHODS: Seventy-three patients who were asymptomatic for CAD and had suspected OSAS were referred to overnight attended polysomnography. Patients were classified into 4 groups according to the Apnea-Hypopnea Index (AHI). All patients underwent computed tomographic examination for tomographic coronary calcification scoring. Physical examination, sleep study recordings, complete blood count and serum biochemistry were obtained from all patients. RESULTS: In the whole group, AHI levels were weakly correlated with coronary calcium score (r = 0.342, p = 0.003) and body mass index (r = 0.337, p = 0.004), moderately correlated with basal oxygen saturation (r = -0.734, p < 0.001), and strongly correlated with oxygen desaturation index (r = 0.844, p < 0.001). In an univariate analysis, age, AHI, basal oxygen saturation, and oxygen desaturation index were associated with CAC in patients with OSAS. In a multiple logistic regression model, age (OR 1.108,%95 CI 1.031-1.191, p = 0.005) and AHI (OR 1.036,% 95 CI 1.003-1.070, p = 0.033) were only independent predictors of CAC in patients with OSAS with a sensitivity of 88.9% and 77.8% and a specificity of 54.3% and 56.5% respectively. CONCLUSIONS: Our findings suggest that in patients with moderate or severe OSAS and advanced age, physicians should be alert for the presence of subclinical atherosclerosis.

Central diastolic blood pressure is associated with the degree of coronary collateral development.

Coronary collaterals (CCs) serve as alternative conduits for blood flow in obstructive coronary artery disease. We investigated the association of various components of blood pressure (BP) parameters with the the degree of coronary collateralization. Patients (n = 245) who underwent coronary angiography were included. Intraarterial BP in the ascending aorta was determined using a standard fluid-filled system. Readings of the conventional peripheral pressure were measured using a manual sphygmomanometer. All blood samples were drawn at admission, before coronary angiography. A total of 65 patients were found to have adequate CC development. Central diastolic BP and peripheral diastolic BP were found to be lower in the group with adequate CC. In multivariate logistic regression model, central diastolic BP and Gensini score were found to be independent predictors of adequate CC. In conclusion, low central diastolic BP in the case of severe coronary stenosis may be an important stimulus for adequate CC development.

Mean platelet volume: an important predictor of coronary collateral development.

Collaterals, which develop in response to ischemic stimuli derived from coronary artery disease (CAD), contribute to reduction of infarct size, left ventricular dysfunction, and mortality. However, there is considerable variation among patients with coronary heart disease regarding the extent of coronary collateral development (CCD). In this study, we aimed to investigate the association of the degree of platelet activation via mean platelet volume (MPV) with coronary collateral circulation. Therefore, 210 patients who underwent coronary angiography and had coronary stenosis ≥50 % in at least one coronary artery were included in the study. Clinical information and analyses of blood samples were obtained from a review of the patients' chart. Blood samples for MPV were analyzed by K3 EDTA and collateral vessels were graded according to the Rentrop classification. In the study group, 150 of the 210 patients were found to have inadequate CCD. Although there was no difference between the two groups with regard to platelet count, MPV levels were significantly higher in the patients who had inadequate CCD (11.3 ± 1.0 fl vs. 9.5 ± 1.5 fl, p < 0.001). Furthermore, the Gensini score was significantly lower in patients who had inadequate CCD (45 ± 46 vs. 91 ± 35, p < 0.001). MPV, Gensini score, age, female gender, total cholesterol, red cell distribution width, triglyceride, and fasting glucose levels were found to have univariate association with poor CCD. In multivariate logistic regression model, MPV (OR = 2.45, p < 0.001) and Gensini score (OR = 0.98, p < 0.001) were found to be the independent predictors of impaired CCD. In receiver operator characteristic curve analysis, optimal cut-off value of MPV to predict inadequate CCD was found as >9.6 fl, with 96% sensitivity and 84.7% positive predictive value. In conclusion, we can say that MPV is an important, simple, effortless, and cost effective tool and can be useful in predicting the CCD in patients with significant CAD.

Serum γ-glutamyltransferase levels correlate with epicardial adipose tissue thickness in patients with coronary artery disease.

Epicardial adipose tissue (EAT) is related to the presence of coronary artery disease (CAD). Increased γ-glutamyltransferase (GGT) activity is associated with atherosclerosis. We assessed the relationship between EAT and serum GGT activity in addition to cardiovascular risk factors in patients with stable anginal symptoms. Consecutive patients (n = 120) who underwent coronary angiography were included. Epicardial adipose tissue thickness was measured by echocardiography. Serum GGT activity was measured by enzymatic colorimetric assay. Epicardial adipose tissue thickness and serum GGT activity were higher in patients with CAD (n = 83). Patients with metabolic syndrome (n = 83) were found to have higher EAT thickness. Serum GGT activity was independently associated with EAT values. In conclusion, echocardiographic EAT was significantly higher in patients with CAD and serum GGT activity correlated with EAT thickness.

Palmar psoriasis, a rare side effect of beta-blocker theraphy: a case report.

A 45-year-old woman presented to our outpatient clinic with reddish eruptions in both palms. We have learned that she was prescribed metoprolol at another medical center to treat new onset hypertension. On her physical examination there were no associated lesions on the body. All other physical findings, as well as blood chemistry, urine analysis, and complete blood count, were found to be normal. After her consultation with the dermatology department, palmar psoriasis due to metoprolol therapy was diagnosed. The personal and family history of the patient yielded no history for psoriasis. Metoprolol therapy was withdrawn and topical treatment with corticosteroid was recommended. The patient has returned to the clinic subsequently, with no recurrence of the lesions. Psoriazis is one of the rare side effects of beta-blocker therapy.

Increased γ-glutamyl transferase levels predict early mortality in patients with acute pulmonary embolism.

BACKGROUND: Increased γ-glutamyl transferase (GGT) level is associated with increased oxidative stress, all-cause mortality, the development of cardiovascular disease, and metabolic syndrome. However, its role in acute pulmonary embolism (PE) is unknown. In this study, we aimed to investigate the relationship between GGT and early mortality in patients with acute PE. METHODS: A total of 127 consecutive patients with confirmed PE were evaluated. The optimal cutoff value of GGT to predict early mortality was measured as more than 55 IU/L with 94.4% sensitivity and 66.1% specificity. Patients with acute PE were categorized prospectively as having no increased (group I) or increased (group II) GGT based on a cutoff value. RESULTS: Of these 127 patients, 18 patients (14.2%) died during follow-up. Among these 18 patients, 1 (1.4%) patient was in group I, and 17 (30.9%) patients were in group II (P < .001). γ-Glutamyl transferase level on admission, presence of shock, heart rate, oxygen saturation, right ventricular dilatation/hypokinesia, main pulmonary artery involvement, troponin I, alanine aminotransferase, alkaline phosphatase, and creatinine levels were found to have prognostic significance in univariate analysis. In the multivariate Cox proportional hazards model, GGT level on admission (hazard ratio [HR], 1.015; P = .017), presence of shock (HR, 15.124; P = .005), age (HR, 1.107; P = .010), and heart rate (HR, 1.101; P = .032) remained associated with an increased risk of acute PE-related early mortality after the adjustment of other potential confounders. CONCLUSIONS: We have shown that a high GGT level is associated with worse hemodynamic parameters, and it seems that GGT helps risk stratification in patients with acute PE.

Echocardiographic epicardial adipose tissue predicts subclinical atherosclerosis: epicardial adipose tissue and atherosclerosis.

We examined the relationship between coronary flow rate and epicardial adipose tissue (EAT) in patients with slow coronary flow (SCF) and normal coronary arteries. The study included 40 consecutive patients with stable angina pectoris who had normal coronary arteries. All patients underwent echocardiography. To determine the SCF, thrombolysis in myocardial infarction (TIMI) frame count method was used. Half of the patients had SCF at least in 1 coronary artery. Thrombolysis in myocardial infarction frame counts, the mean TIMI frame count, and EAT thickness were significantly higher in patients with SCF. Slow coronary flow showed a significantly positive correlation with EAT thickness. Epicardial adipose tissue thickness was the only independent predictor of SCF. Our findings suggest that there is a significant correlation between the SCF and EAT. Therefore, echocardiographic EAT may become a predictor of subclinical atherosclerosis in patients with stable angina pectoris.