Methylenetetrahydrofolate reductase gene polymorphism and risk of premature myocardial infarction.

BACKGROUND: Elevated plasma homocysteine level is an independent risk factor for cardiovascular disease. A common mutation (nucleotid 677C-T) in the gene coding for methylenetetrahydrofolate reductase (MTHFR) has been reported to reduce the enzymatic activity of MTHFR and is associated with elevated plasma levels of homocysteine, especially in subjects with low folate intake. HYPOTHESIS: Methylenetetrahydrofolate reductase T/T genotype may be a risk factor for premature MI in Turkish population who are known to have low folate levels. METHODS: The study group was comprised of 96 men (aged <45 years) with premature myocardial infarction (MI) and 100 age- and gender-matched controls who had no history or clinical evidence of coronary artery disease (CAD) and/or MI. DNA was extracted from peripheral blood and genotypes were determined by polymerase chain reaction, restriction mapping with HinfI, and gel electrophoresis. Conventional risk factors for CAD were prospectively documented. RESULTS: Allele and genotype frequencies among cases and control subjects were compatible with Hardy-Weinberg equilibrium. The frequencies of T/T, C/T, and C/C genotypes among patients with MI and control subjects were 15.6, 40.6, and 43.8%, and 5, 35, and 60%, respectively. Multivariate analyses identified smoking, MTHFR C/T polymorphism, diabetes mellitus, family history of CAD, and hypertension as the independent predictors of premature MI. Defining patients with non-T/T genotype (C/C and C/T combined) as reference, the relative risk of MI for subjects with T/T genotype was 5.94 (95% confidence interval: 1.96-18.02, p = 0.0016). CONCLUSIONS: Our findings suggest that C677T transition in the MTHFR gene may be a risk factor for premature MI in Turkish men.

Bronchial hyperreactivity in patients with mitral stenosis before and after successful percutaneous mitral balloon valvulotomy.

OBJECTIVES: We aimed to identify the bronchial response to inhaled methacholine in patients with mitral stenosis (MS) and to clarify whether or not the bronchial hyperreactivity (BHR) is reversible after percutaneous mitral balloon valvulotomy (PBMV). PATIENTS AND SETTING: Thirty patients with MS and 28 age-matched healthy control subjects were prospectively evaluated with pulmonary function tests and methacholine challenge. The productive concentration of methacholine causing 20% decrease in FEV(1) (PC(20)) was calculated and used as a parameter of bronchial responsiveness. BHR was defined as a PC(20) < 8 mg/mL. Mean pulmonary artery pressure (PAP) and mean pulmonary capillary wedge pressure (PCWP) were recorded in all patients through a Swan-Ganz balloon-tipped catheter. Sixteen patients underwent PMBV, and a methacholine test was repeated after each procedure. RESULTS: Bronchial response to methacholine was significantly increased in patients with MS, so that 53% of them had BHR, whereas all control subjects were nonresponders. The PC(20) was closely correlated with the PAP (r = - 0.777; p < 0.001), PCWP (r = - 0.723; p < 0.001), and mitral valve area (MVA; r = 0.676; p < 0. 001). Balloon valvulotomy was successfully performed in all of the 16 patients, and the cardiac parameters (MVA, PAP, and PCWP) significantly improved after the procedure. In contrast, no significant changes were shown in pulmonary function test variables (total lung capacity, vital capacity [VC], FEV(1), and FEV(1)/VC). Although significant improvement was observed in the mean PC(20) values (from 4.97 +/- 5.24 to 7.47 +/- 6.96 mg/mL; p = 0.0006), BHR was completely eliminated in only one patient. CONCLUSIONS: Our data shows that BHR is fairly common among patients with MS, and severity of bronchial responsiveness is significantly correlated with the severity of MS. Moreover, PMBV leads to significant reduction in pulmonary congestion and a consequent improvement in BHR.

A case of type IV dual left anterior descending artery associated with anomalous origin of the left circumflex artery in the presence of coronary atherosclerosis.

Double origin of the left anterior descending coronary artery (LAD) from the left and right coronary arteries (type IV dual LAD) is a rare coronary anomaly. We report an unusual case of type IV dual LAD associated with anomalous origin of the left circumflex artery from the right coronary artery in a patient with a recent history of myocardial infarction. The first diagonal branch originating from the short LAD demonstrated 70-80% stenosis and the posterior descending artery was totally occluded. We believe that this unusual variance of the coronary arteries in association with atherosclerosis has not been previously reported.

Deletion polymorphism at the angiotensin-converting enzyme gene in Turkish patients with coronary artery disease.

Coronary artery disease (CAD) is a multifactorial disease in which genetic and environmental factors play an important role. These factors differ in each population. This study was carried out to determine whether there is an association between insertion/deletion (I/D) polymorphism and CAD in Turkish patients from Ankara. An I/D polymorphism in intron 16 of the gene coding for the angiotensin-converting enzyme (ACE) has been used to study the role of this gene in the aetiology of coronary atherosclerosis and hypertension. As there are no existing data for the Turkish population, we studied the I/D polymorphism of the ACE gene in 218 patients with CAD and 107 controls. Polymerase chain reaction (PCR) was used for genotyping the I and D alleles. The DD polymorphism of the ACE gene was significantly different between CAD subjects (0.733) and controls (0.612) (p=0.002). The observed heterozygosity was 29.3% and 43.9% and D allele frequency was 0.733 and 0.612, respectively. There was a significantly higher D allele (p=0.03) in 111 patients with myocardial infarction (MI) compared with controls. Furthermore, MI localization also gave a significance of p=0.002 for inferior MI but not for anterior MI (p=0.83). Forty-three hypertension patients had a D allele frequency of 0.767 which was significantly different from control (p=0.01). These data provide further evidence for the association of D allele and CAD in a Turkish population.

Improvement of Left Ventricular Function and Wall Motion Abnormalities after Recanalization of Total Occlusion of Left Anterior Descending Coronary Artery by Percutaneous Transluminal Coronary Angioplasty.

PTCA was performed in 262 consecutive patients (pts) with total LAD occlusion. TIMI 3 flow was established in 164 pts (success rate was 62.6%). After 4Ð6 months a follow-up angiography of 72 pts showed restenosis in 39 pts (restenosis rate was 54.2%). In 33 pts without restenosis there was a significant increase in ejection fraction (EF) (54.6 +/- 15 versus 59.8 +/- 18.1 before and after PTCA respectively, p = 0.02). Improvement of wall motion abnormalities (WMA) in 12 of 26 pts was observed. Anterolateral-apical (AL-A) aneurysm disappeared in 6 pts and limited to apex in 2 pts. AL-A hypokinesia in 3 and akinesia in 1 reversed to normal wall motion (NWM). There was not a significant change in EF in either of the groups of pts with reocclusion (24 pts) or restenosis (15 pts) (p > 0.05). However, AL-A aneurysm disappeared in 2 of 12 pts with WMA before PTCA although there was restenosis (but TIMI 3 flow) on follow-up coronary angiogram. In 3 pts with restenosis but not reocclusion AL-A hypokinesia, akinesia and apical dyskinesia returned to NWM. No significant changes were observed in the left ventricular end diastolic pressures (LVEDP) in both pt groups with or without improvement of WMA(p > 0.05). Filling fractions (FF) did not change in patients with or without restenosis. CONCLUSION: The observations in patients with successful total LAD occlusion angioplasty and no restenosis are as follows: 1) There was a significant increase in EF; 2) There was no significant decrease in LVEDP and no increase in FF; 3) The rate of improvement of WMA was 46.2%; 4) There was no relation between improvement of WMA and the age of occlusion, the grade of coronary collateral vessels and involvement of other coronary arteries. However, it has been emphasized that in 11 of 12 pts (91.6%) with improvement of WMA the age of occlusion was < 3 months, in 10 (83.3%) the grade of coronary collateral vessels was 2 or 3 and in 10 (83.3%) the other coronary arteries were normal. The improvement of WMA in 41.6% of pts. who had also subtotal restenosis but not reocclusion was observed. Finally in 72 pts with follow-up coronary angiography, the rate of improvement of wall motion was 23.5 %.

Left ventricular filling and ejection fraction after successful percutaneous balloon mitral valvuloplasty.

The effect of percutaneous balloon mitral valvuloplasty (PBMV) on left ventricular (LV) filling and ejection fraction (EF) still remains controversial. We evaluated LV filling and EF in 23 patients (19 women and four men, mean age 35.6+/-9.6, range 17-56 years) with mitral stenosis (MS) and sinus rhythm immediately before and after successful PBMV not complicated with significant mitral regurgitation and arrhythmia during left ventriculography. After PBMV mean mitral valve area increased from 1.4+/-0.2 to 2.2+/-0.3 cm2 (P<0.01), mean mitral valve gradient (MVG) decreased from 18.6+/-5.7 to 6.9+/-3.2 mmHg (P<0.01) and mean left atrial pressure (LAP) decreased from 26.0+/-8.2 to 12.3+/-5.2 mmHg (P<0.01). We did not determine any change in EF (before PBMV 61.8+/-9.3% and after PBMV 61.8+/-7.6% (P>0.05)). Heart rate did not change significantly before and after valvuloplasty (P>0.05). Despite the decrease in LAP and MVG, the early diastolic filling fraction of left ventricle did not change (before PBMV 59.5+/-7.5%, after PBMV 57.8+/-8.9% (P>0.05)). Also, we did not determine any increase in LV end diastolic volume index (before PBMV 89.9+/-27.7 cm3/m2 and after PBMV 84.6+/-20.9 cm3/m2 (P>0.05)). However, LV end diastolic pressure increased significantly after PBMV (from 6.6+/-3.0 to 11.3+/-4.9 mmHg (P<0.01)). We conclude that in patients with MS, LV diastolic performance is impaired and LV EF does not change acutely after PBMV.

Significance of dual left anterior descending coronary artery in interventional cardiology. A case report.

The variants of the left anterior descending (LAD) coronary artery are important in interpretation of coronary angiograms and in interventional procedures. The authors present a patient who had percutaneous transluminal coronary angioplasty and stent implantation to a presumed proximal LAD without the realization that dual LAd was present because of the total occlusion of the long LAD.

Coronary artery aneurysms. Report of two cases and review of the literature.

Two patients who had angiographically proven coronary artery aneurysms are presented. The clinical pictures of these patients were similar to that of patients with atherosclerotic coronary artery disease. Both had severe angina pectoris, and the second patient (case 2) had had myocardial infarction. Their coronary artery aneurysms were single, fusiform (case 1) and saccular (case 2) in shape and not associated with extensive coronary atherosclerosis. They were treated medically and did well.

Percutaneous transluminal coronary angioplasty of anomalous coronary arteries. Case reports.

To date, technical experience reported in the literature is very limited on angioplasty in patients with anomalous coronary arteries. Balloon angioplasty may be a more favorable approach for revascularization in these vessels. A major factor is selection of the guiding catheter. The authors report 4 patients with severe atherosclerotic lesions of anomalous coronary arteries who underwent coronary angioplasty of the anomalous vessel. Three patients had an anomalous circumflex artery and 1 had an anomalous right coronary artery. Angiographic and clinical success were achieved in 3 patients.

Hugging balloon angioplasty of right coronary artery.

We report a case of "hugging balloon" dilatation of a giant right coronary artery using two dilatation catheters, a balloon "on a wire" and a balloon "rapid exchange" systems via a single guiding catheter. The necessity of larger PTCA balloon catheter (> 4.0 mm) was stressed.

Restenosis after transluminal coronary angioplasty: a risk factor analysis.

BACKGROUND: Restenosis after percutaneous transluminal coronary angioplasty (PTCA) is a major problem limiting the long-term efficacy of the procedure. The purpose of this study was to determine whether risk factors such as cigarette smoking, diabetes mellitus, hypertension or hypercholesterolaemia correlate with restenosis after PTCA. We also studied the relationship between a history of previous myocardial infarction and the extent of coronary artery disease (single-, two- or three-vessel) with restenosis after coronary angioplasty. METHODS: A total of 360 patients underwent successful PTCA. Follow-up coronary angiograms were performed in 181 patients after a mean +/- SD period of 6 +/- 4 months. RESULTS: The restenosis rate was 49%. We divided the patients into two groups: 89 patients with restenosis (8 women and 81 men) and 92 patients with no restenosis (14 women and 78 men). Age, sex, a history of cigarette smoking, diabetes mellitus and a history of previous myocardial infarction were not associated with restenosis. Serum levels of triglyceride were also unrelated to the restenosis rate. Restenosis was associated with hypertension, low levels of high-density-lipoprotein cholesterol, high levels of low-density-lipoprotein cholesterol and high total cholesterol levels (P < 0.001). Patients with two-vessel or multivessel disease had significantly higher restenosis rates than patients with single-vessel disease (P < 0.001). CONCLUSION: Patients with hyperlipidaemia, hypertension and multi-vessel disease appear to be higher risk of recurrent restenosis.

Effects of percutaneous transluminal coronary angioplasty on late potentials and high frequency mid-QRS potentials.

The high frequency mid-QRS potentials and late potentials are important in coronary artery disease because they are related to the extent of ischemia and prognosis. In this study, the effects of successful percutaneous transluminal coronary angioplasty (PTCA) on these potentials were evaluated. Twenty-four patients with coronary artery disease (aged 34-67 years, 5 women, 19 men) were examined. Eight of these patients had a history of myocardial infarction (4 anterior, 3 inferior, 1 anterior and inferior). Signal averaged ECG was recorded at 40- to 250-Hz frequency ranges for late potentials and 150- to 250-Hz frequency ranges for mid-QRS potentials before PTCA, and they were repeated 1 month later. The QRS duration (107.7 +/- 9.8 to 105.3 +/- 9.3 ms, p < 0.0001) root-mean-square voltage (39.4 +/- 20.1 to 47.7 +/- 22.2 microV, p < 0.00001) and low amplitude signal duration (30.7 +/- 9.9 to 27.7 +/- 9.3 ms, p < 0.001) showed significant changes in 40- to 250-Hz ranges before and after PTCA. The same results were also obtained in the 150- to 250-Hz frequency ranges: the QRS duration decreased (90.9 +/- 9.8 to 86.5 +/- 9.1 ms, p < 0.005) and the root-mean-square voltage increased (5.5 +/- 1.6 to 6.1 +/- 1.8 microV, p < 0.00001). Thus, successful PTCA causes improvement in late potential parameters, so the risk of malign arrhythmia that affects the prognosis can be reduced. Additionally, the increase in high frequency mid-QRS potentials shows the decrease in the ischemia after PTCA.

Cardioinhibitory response to carotid sinus massage in patients with coronary artery disease.

The relationship between cardioinhibitory response to the carotid sinus massage and the severity of coronary artery lesions and left ventricular impairment was investigated in 86 patients who underwent coronary angiography. The study group (Group 1) comprised 63 patients who had coronary lesions and the control group (Group 2) comprised 23 patients who had normal coronary arteries. There was no significant relationship between the severity of coronary artery lesions and the cardioinhibitory response to the carotid sinus massage in the study group. However, there was a positive correlation (r = 0.478, P < 0.01) between total left ventricular segment scores and the maximal change in RR interval (%) during the right carotid sinus massage in the study group. During the right carotid sinus massage, maximal change of RR interval (%) was significantly higher in patients who had segmental wall motion abnormalities than in patients who did not (83.0 +/- 72.4% vs. 32.9 +/- 42.5%, P < 0.01, respectively). In the patients who could have echocardiographic measurements there was negative correlation between fractional shortening value and maximal change of RR interval (%) (right massage; r = -0.482, P < 0.01, left massage; r = -0.334, P < 0.05). In conclusion, we found a significant relationship between the cardioinhibitory response to carotid sinus massage and the presence and severity of the segmental wall motion abnormalities and left ventricular impairment in patients with coronary artery disease.

Pericardial involvement in familial Mediterranean fever.

Two patients with familial Mediterranean fever showed the classic features of pericardial involvement and one of them (Case 2) had pericardial effusion detected by echocardiography. These and previously published cases show that familial Mediterranean fever should be considered as a cause of pericarditis and/or pericardial effusion.

Acute myocardial infarction and normal coronary arteries in a pregnant woman.

As it is a rare case, we report a 37-year-old woman who had transmural myocardial infarction in her last trimester. Coronary arteriography done 15 days after her normal delivery showed normal coronary arteries and left ventriculography showed an apical aneurysm. The proposed cause appears to be coronary spasm.