The effect of RAAS inhibitors on acute hypoxemic respiratory failure and in-hospital mortality in the hypertensive Covid-19 patients.

INTRODUCTION: We have aimed to investigate the relationship between use of angiotensin-converting-enzyme inhibitor (ACEI) or angiotensin-receptor-blocker (ARB) drugs and acute hypoxemic respiratory failure (AHRF) and in-hospital mortality in hypertensive Covid-19 patients. MATERIAL AND METHOD: Consecutive 1345 patients diagnosed with Covid-19 between April and October 2020 who met inclusion criteria were divided into two groups based on presence and absence of AHRF and mortality. The groups were compared regarding epidemiological, clinical, radiological, laboratory findings and treatments methods. The patient groups ACEI, ARB and other antihypertensive drugs (non-ACEI/ARB) were compared regarding same parameters. RESULTS: Median age was 68 (60-76) years in the patient group including 805 (59.9.1%) females. Of the patients, 475 (35.3%), 644 (47.9%) and 226 (16.8%) were using ACEIs, ARBs and non-ACEI/ARB, respectively. AHRF and in-hospital mortality developed in 1053 (78.3%) and 290 (21.6%) patients, respectively. Age, gender, coronary artery disease, diabetes mellitus (DM), neutrophil, lymphocyte, creatinine, D-dimer, C-reactive protein (CRP), ACEI, beta blocker and aspartate transaminase (AST) found statistically significant in the univariable logistic regression performed to identify independent predictors of mortality were included multivariable logistic regression model. Age (OR: 1.066, 95%CI: 1.049-1.083; p < .001), DM (OR: 1.682, 95%CI: 1.238-2.286; p = .001), neutrophil (OR: 1.041, 95%CI: 1.007-1.077; p = .019), creatinine (OR: 1.178, 95%CI: 1.048-1.325; p = .006), CRP (OR: 1.008, 95%CI: 1.006-1.010; p < .001), ACEI (OR: 0.718, 95%CI: 0.521-0.988; p = .042), AST (OR: 1.005, 95%CI: 1.001-1.010; p = .010) were found associated with in-hospital mortality. CONCLUSION: In our study, it was not detected clinically significant difference between three groups with regard to their relation with in-hospital mortality.

The association between prolongation in QRS duration and presence of coronary collateral circulation in patients with acute myocardial infarction.

BACKGROUND: It is known that QRS duration is related to prognosis in acute myocardial infarction. The relation between QRS duration and coronary collateral circulation is uncertain. In the present study, we aimed to determine the relation between QRS duration and coronary collateral circulation in patients admitted with acute myocardial infarction. METHODS: The present study was composed of 109 consecutive patients with acute myocardial infarction. All patients had total occlusion in the left anterior descending coronary artery. Electrocardiographic recordings on admission were obtained for the assessment of QRS duration. The Rentrop classification was used to define coronary collateral circulation on coronary angiography. Patients were divided into two groups as follows: Group 1 with poor coronary collateral circulation (Rentrop 0-1) and Group 2 with good coronary collateral circulation (Rentrop 2-3). RESULTS: Of all patients, 62 patients were included in group 1 and 47 patients in group 2, respectively. In the present study, patients in the group 1 had longer QRS duration than patients in the group 2 (p < 0.005). Additionally, we found that Rentrop grading had negative correlation with both QRS duration and white blood cell count (r: -0.28; p < 0.005 and r: -0.35; p < 0.001). CONCLUSION: Our study showed that there was an inverse relationship between QRS duration on admission and presence of coronary collateral circulation in patients with acute myocardial infarction.

Association Between ACE Gene Polymorphism and QT Dispersion in Patients with Acute Myocardial Infarction.

BACKGROUND: Angiotensin converting enzyme (ACE) gene polymorphism is associated with high renin-angiotensin system causing myocardial fibrosis and ventricular repolarization abnormality. Based on these findings, this study was designed to determine the association between ACE gene insertion/deletion (I/D) polymorphism and QT dispersion after acute myocardial infarction (MI). OBJECTIVE AND METHODS: The study included 108 patients with acute MI. Blood samples were obtained from all the patients for genomic DNA analysis. ECGs were recorded at baseline and at the end of a 6-month follow up. The OT dispersion was manually calculated. RESULTS: The mean age of the patients was 57.5 ±9.9 years (ranging from 36 to 70). The patients with DD genotype showed longer QT dispersion than patients with II or DI genotype at the baseline, while at the end of the six-month follow up the patients with DI genotype showed longer QT dispersion than patients with DD or II genotypes. However, the magnitude of the QT dispersion prolongation was higher in patients carrying the ACE D allele than patients who were not carrying it, at baseline and at the end of six-month follow up (52.5 ±2.6 msn vs. 47.5±2.1 msn at baseline, 57±3.2 msn vs. 53±2.6 msn in months, P: 0.428 and P: 0.613, respectively). CONCLUSION: Carriers of the D allele of ACE gene I/D polymorphism may be associated with QT dispersion prolongation in patients with MI.An interaction of QT dispersion and ACE gene polymorphism may be associated with an elevation of serum type I-C terminal pro-collagen concentration, possibly leading to myocardial fibrosis, and increased action potential duration.

Neutrophil/lymphocyte ratio is associated with right ventricular dysfunction in patients with acute inferior ST-segment elevation myocardial infarction.

BACKGROUND: Acute inferior ST-segment elevation myocardial infarction (STEMI) is associated with increased in-hospital morbidity and mortality particularly among patients with coexisting right ventricular (RV) involvement. High neutrophil to lymphocyte ratio (NLR) is an independent predictor of major adverse cardiac events and mortality in patients with myocardial infarction. This study evaluated the relationship between the NLR and RV dysfunction (RVD) in patients with inferior STEMI who underwent primary percutaneous coronary intervention (PCI). METHODS: A total of 213 subjects with inferior STEMI were divided into two groups according to the presence of RVD. The groups were compared according to NLR and receiver operating characteristic (ROC) analysis was performed to access the predictability of NLR on having RVD. RESULTS: The NLR was significantly higher in the group with RVD compared to that without RVD (p < 0.001). In ROC analysis, NLR > 3.5 predicted RVD with sensitivity of 83% and specificity of 55%. In a multivariate regression analysis, NLR remained an independent predictor of RVD (OR 1.55, 95% CI 1.285-1.750, p < 0.001). CONCLUSIONS: NLR was an independent predictor of RVD in patients with inferior STEMI undergoing primary PCI.

Effect of Hematologic Parameters on Microvascular Reperfusion in Patients With ST-Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention.

OBJECTIVES: Despite the significant role of certain hematologic parameters in reperfusion injury, their relationship with microvascular reperfusion remains not well understood. Therefore, our objective was to evaluate the relationship between hematologic parameters at admission and microvascular reperfusion in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (primary PCI). METHODS: A total of 213patients (mean age: 57.5 ± 11 years) with STEMI were included. Blood samples were obtained from all patients prior to primary PCI. Electrocardiographic recordings were made for the evaluation of ST-segment resolution (STR) before and after primary PCI. Angiographic assessment in the infarct-related artery was performed using the myocardial blush grade (MBG) and thrombolysis in myocardial infarction (TIMI) flow. Patients were categorized into 2 groups as those with impaired microvascular reperfusion (STR <70%, TIMI: 0-1, and MBG: 0-1) and those with normal microvascular reperfusion (STR >70%, TIMI: 2-3, and MBG: 2-3). RESULTS: Of the overall study group, 139, 105, and 69 patients had an STR of <70%, MBG of 0-1, and TIMI of 0-1, respectively. Demographic parameters in both groups are shown in the tables. Patients with impaired microvascular reperfusion were found to have higher white blood cell (WBC) count, neutrophil count, lymphocyte count, and mean platelet volume (MPV). Neutrophil-lymphocyte ratio and platelet count were similar between the 2 groups. Correlation analysis showed a negative correlation between lymphocyte count and STR (r: -.195, P: .004), lymphocyte count and TIMI flow(r: -.09, P: .14), and lymphocyte count and MBG (r: -.211, P: .002). CONCLUSION: Our results suggest that higher WBC count and MPV at admission are independent predictors of impaired microvascular perfusion in patients with STEMI. On the other hand, a negative correlation was found between lymphocyte count and impaired microvascular perfusion. Specifically, elevated lymphocyte count seemed to indicate the presence of impaired microvascular reperfusion in patients with STEMI.

Relation between Apolipoprotein E Gene Polymorphism and Severity of Coronary Artery Disease in Acute Myocardial Infarction.

Apolipoprotein E (ApoE) is a plasma protein and associated with cholesterol transport system. In several studies, the relationship between ApoE gene polymorphism and severity of coronary artery disease (CAD) has been shown. However, the relationship between ApoE gene polymorphism and severity of CAD in patients with acute myocardial infarction (MI) has not been well known. The aim of this study is to investigate the relation between ApoE polymorphism and severity of CAD in patients with acute MI by using the Gensini Score. In this study, 138 patients were admitted to cardiology clinic with diagnosis of acute MI, and angiographic assessment was performed using the Gensini Score. Blood samples were obtained from all patients in the first day. The patients with ApoE34 genotype had high Gensini scores. Besides, the patients with E4 allele carriers were associated with high Gensini score compared with the patients without E4 allele carriers (p:0,22). The patients with E4 allele carriers were associated with higher LDL cholesterol and total cholesterol compared with the patients without E4 allele carriers (p:0,001 and p:0,03, resp.). There were no statistically significant differences between ApoE genotypes and severity of CAD by using the Gensini Score. But, the patients with E4 allele carriers were associated with high lipid levels.

QRS duration: a novel marker of microvascular reperfusion as assessed by myocardial blush grade in ST elevation myocardial infarction patients undergoing a primary percutaneous intervention.

OBJECTIVES: Prolonged QRS duration is a predictor of poor prognosis in patients with coronary artery disease. The association between the duration of QRS and myocardial reperfusion is not very well understood. Our aim was to assess the relationship between the measurements of QRS duration and myocardial blush grade (MBG) in patients with ST elevation myocardial infarction (STEMI) who were treated with a primary percutaneous intervention. PATIENTS AND METHODS: A total of 213 patients (mean age: 57.5±11 years) with STEMI were included. ECG recordings were obtained for the evaluation of the QRS duration before and after primary percutaneous coronary intervention. Angiographic assessment in the infarct-related artery was performed using the MBG. Patients were categorized into two groups of those with impaired microvascular reperfusion (MBG: 0-1) and those with normal microvascular reperfusion (MBG: 2-3). RESULTS: Overall, 105 and 108 patients had an MBG of 0-1 or 2-3, respectively. There is no significant difference between patient's characteristics. Despite the absence of a difference between two groups in terms of the QRS duration at presentation (P: 0.57), patients with impaired microvascular reperfusion were found to have longer QRS duration at immediately postprocedure (P: 0.003) and postprocedure 60 min time-points (P<0.001). Correlation analyses showed a positive correlation between pain-to-balloon time and QRS duration at postprocedure 60 min time-points (r: 0.137 and P: 0.04). CONCLUSION: Our results suggest that longer QRS duration after angioplasty seemed to indicate the presence of impaired microvascular reperfusion in patients with STEMI.

High levels of high sensitivity C-reactive protein predict the progression of chronic rheumatic mitral stenosis.

BACKGROUND: High sensitive C-Reactive Protein (hs-CRP) predicts morbidity and mortality in various clinical conditions. The effect of hsCRP on progression of chronic rheumatic mitral stenosis (CRMS) has not been demonstrated. METHODS AND RESULTS: A total of 132 patients with CRMS (95 female, 37 male) and 145 control (100 female, 45 male) were included in the study. Baseline clinical, echocardiographic, hematologic and hs-CRP measurements were collected prospectively. Mean mitral valve area (MVA) was 1.4 +/- 0.3 cm(2), mean wilkins valve score value was 8.9 +/- 1.7, left atrial diameter was 5.0 +/- 0.7 cm, left atrial area was 37.2 +/- 12.6 cm(2), and systolic pulmonary arterial pressure (SPAP) was 44 +/- 11 mmHg in patients with CRMS. The mean levels of hs-CRP value, fibrinogen, and mean platelet volume (MPV) were significantly higher in CRMS group compared to control group. The levels of hsCRP were found to be positively correlated with mean Wilkins valve score value, SPAP, presence of atrial fibrillation (AF), left atrial diameter, left atrial area, presence of LASEC(+), fibrinogen, and MPV and inversely correlated with MVA in patients with CRMS. Linear regression analysis revealed that the hsCRP level independently affects mean Wilkins valve score value, left atrial area (LAA), LASEC(+) and AF in the patients with CRMS. CONCLUSIONS: These results suggest that increased hsCRP levels are associated with CRMS severity. These association may be important when treating patients with CRMS.

[High levels of high-sensitivity C-reactive protein and impaired autonomic activity in smokers]. / Sigara içenlerde artmis yüksek duyarlikli C-reaktif protein düzeyleri ve bozulmus otonomik aktivite.

OBJECTIVES: We investigated the relationship between high sensitivity C-reactive protein (hs-CRP) activity and autonomic nervous activity using heart rate variability in smokers. STUDY DESIGN: The study consisted of 136 healthy subjects, including 66 smokers (35 women, 31 men; mean age 36 years) and 70 nonsmokers (43 women, 27 men; mean age 34 years). Serum samples were collected from all the subjects. Three-channel, 24-hr Holter monitoring was performed to derive the mean heart rate, standard deviation of normal NN intervals (SDNN), standard deviation of 5-minute mean NN intervals (SDANN), root mean square differences of successive NN intervals (RMSSD), high- (HF) and low- (LF) frequency power components, and the LF/HF ratio. RESULTS: In smokers, the mean duration of smoking was 13.6+/-8.2 years (range 3 to 45 years), and the mean number of cigarettes consumed per day was 16.3+/-7.1 (range 5 to 40). Smokers exhibited significantly higher mean heart rate, hs-CRP and fibrinogen levels, mean platelet volume, white blood cell count, LF, and LF/HF ratio, with significantly lower SDNN, SDANN, RMSSD, and HF values. In smokers, hs-CRP was correlated with the number of cigarettes consumed per day, duration of smoking, fibrinogen level, mean platelet volume, white blood cell count, LF, and LF/HF ratio, and inversely correlated with HF, SDNN, and SDANN. Even smoking a single cigarette resulted in an acute, 0.07-fold increase in the hs-CRP level (p<0.0001). In linear regression analysis, both the number of cigarettes consumed per day (beta=0.52, p=0.011) and duration of smoking (beta=0.073, p<0.0001) had an independent effect on the hs-CRP level. CONCLUSION: Smoking both impairs the sympathovagal balance and increases the hs-CRP activity in otherwise healthy smokers, the combination of which would probably contribute to a higher rate of cardiovascular events.

Coronary narrowing secondary to compression by pericardial hydatid cyst.

Echinococcus granulosus remains a clinical problem in undeveloped and developing countries. It commonly affects the liver and lung, but, rarely, other organs such as the heart can be involved. In this report, we describe an unusual case in which pericardial hydatid cyst mimicking acute coronary syndrome secondary to compression by pericardial hydatid cyst attached to the anterolateral wall of the left ventricle. We made diagnosis by transthoracic 2D echocardiography, and confirmed by cardiac magnetic resonance imaging and serologic tests. Because our patient refused to have an operation, albendazole therapy was given. It is important to recognize this unusual disease, because it may lead to serious complications.

Spontaneous coronary artery dissection during hemodialysis in the post-abortion period.

Spontaneous coronary dissection (SCAD) is an unusual cause of acute myocardial infarction with complex pathophysiology. We present a case of acute inferior myocardial infarction resulting from spontaneous coronary artery dissection of the right coronary artery in a 33-year-old woman during the hemodialysis due to a recent abortion and consequent curettage at first trimester of her pregnancy. This report describes a previously healthy woman without traditional cardiovascular risk factors who presented with an acute inferior myocardial infarction. Spontaneous coronary artery dissection (SCAD) should be considered as a cause of the acute myocardial infarction in young patients without traditional risk factors for coronary artery disease, in females in the both peri-partum and post-abortion period.

Pulmonary hypertension in patients with essential thrombocythemia and reactive thrombocytosis.

Increased incidence of pulmonary hypertension (PH) has been reported in patients with chronic myeloproliferative disorders. The exact incidence of PH in essential thrombocythemia (ET) is unknown. Most of the reported literature consists of case reports or small studies. We designed this study to asses the incidence of PH in patients with ET and reactive thrombocytosis. Previously or newly diagnosed 46 patients with ET, and 40 patients with reactive thrombocytosis secondary to iron deficiency anemia were found to be eligible for this study. Diagnosis of PH was established via transthoracic echocardiography. PH was found in 22 (47.8%) out of 46 patients with ET. Seven patients with PH were newly diagnosed ET, 5 patients with PH were in low, and the other patients with PH were in intermediate or high risk category. We found statistically significant difference in terms of platelet counts between ET patients with PH and without PH (p = 0.027). None of the patients with reactive thrombocytosis had PH. In conclusion, PH appears to be common in patients with ET. Therefore, all patients with ET should be evaluated for PH. Larger and prospective studies are required to clarify the long-term impact of PH on the survival of these patients. Future studies are also needed to determine whether cytoreductive treatment and aspirin prevent the development of PH, and to determine the effects of cytoreductive treatments and aspirin on the prognosis of PH. The effect of PH on ET prognosis should also be determined in low risk ET patients.

Coexisting subarachnoid hemorrhage and subdural hematoma mimicking acute anterolateral myocardial infarction.

Ischemic electrocardiographic changes, elevations in cardiac-specific markers such as troponin and creatinine phosphokinase MB, segmental wall motion abnormalities, and myocardial dysfunction may occur after central nervous system events such as subarachnoid hemorrhage, subdural hematoma, and ischemic stroke. The pathophysiology remains unclear, but a catecholamine-induced neurocardiogenic injury has been mentioned as a causative factor. We reported a case of coexisting subarachnoid hemorrhage and subdural hematoma with ischemic electrocardiography changes, increases in cardiac-specific enzymes, and a regional wall motion abnormality despite normal epicardial coronary arteries. It is very important to differentiate neurogenic stunned myocardium from myocardial dysfunction caused by coronary artery disease in patients with intracranial hemorrhages for appropriately managing the treatment of cases.