Low-Dose Slow Infusion Tissue Plasminogen Activator (tPA) in Treatment of Thrombotic Coronary Artery Occlusions: Case Series and Literature Review.

Thrombotic coronary artery occlusions usually manifest as acute coronary syndrome with cardiogenic shock, acute pulmonary edema, cardiac arrest, fatal arrhythmias, or sudden cardiac death. Although it usually occurs based on atherosclerosis, it can also occur without atherosclerosis. There is no predictor of coronary artery thrombosis clinically and no consensus regarding the optimal treatment. In the current literature, treatment options include emergency coronary artery bypass grafting, entrapment of thrombus in vessel wall with stent implantation, intracoronary thrombolysis, glycoprotein IIb/IIIa inhibitors, anticoagulation with heparin, and thrombus aspiration as reperfusion strategies. Here, we reviewed a new treatment strategy based on the literature, and a case series with successful results in hemodynamically stable patients with low-dose slow infusion tissue plasminogen activator (tPA) for thrombotic coronary artery occlusions that allow coronary flow was reported. Prospective randomized studies and common consensus are needed on low-dose, slow-infusion tissue plasminogen activator treatment regimen and optimal treatment management for thrombotic coronary artery occlusions.

Comparison of diagnostic accuracy of point-of-care ultrasonography and X-ray of bony injuries of the knee.

PURPOSE: We aimed to compare the accuracy of point-of-care ultrasonography (POCUS) and X-ray (XR) in the diagnosis of knee bone fractures and fracture characteristics in cases of injuries to the knee. METHODS: The study was conducted in the emergency department (ED) of a tertiary hospital between March 2017 and March 2019. It included patients who presented to the ED with isolated knee injuries, were suspected to have a bony lesion based on clinical examinations, and were ultimately referred for XR. Five emergency physicians (EPs) who had at least three years of ED experience participated in the study. Before the study, these EPs received training on knee examination and radiographic investigation of the knee joint. They were also trained on how to assess the knee joint using POCUS. The knee bones, patella, femur, tibia, and fibula were evaluated. A POCUS examination of the knee bones was carried out according to the eight-step Kozaci Protocol. RESULTS: This study included 92 patients with knee trauma. The mean age of the patients was 34 ± 16 years (6-55 years). Using POCUS and XR, fractures were detected in 40 (43%) and 32 patients (35%), respectively. Relative to XR, for detecting fractures, POCUS showed sensitivity, specificity, positive predictive value, and negative predictive value of 97%, 85%, 78%, 98%, respectively, and the kappa value was 0.774. POCUS examination revealed hematoma and edema in the soft tissue in 34 (37%) patients and hemarthrosis in 33 patients (36%). CONCLUSION: XR is the first and most widely used imaging modality to identify fractures of the knee bone trauma. However, POCUS examination can successfully diagnose bony lesions of the knee in patients with stable vital signs and without life-threatening injuries. It can also easily diagnose hematoma and hemarthrosis. Therefore, POCUS can be used as a diagnostic tool in emergency situations where XR is not available.

The Association of Body Composition Parameters and Simultaneously Measured Inter-Arm Systolic Blood Pressure Differences.

Background and Objectives: An inter-arm systolic blood pressure difference (IASBPD) is defined as a blood pressure (BP) disparity of ≥10 mmHg between arms. IASBPDs are associated with an increased risk of cardiovascular disease (CVD). Similarly, visceral fat accumulation (VFA) is clinically important because it is associated with higher cardiovascular disease risk. Accordingly, this study compared the body composition parameters of IASBPD individuals with individuals who did not express an IASBPD. Materials and Methods: The analysis included 104 patients. The blood pressures of all participants were measured simultaneously in both arms using automated oscillometric devices. Then patients were divided into two groups according to their IASBPD status: Group 1 (IASBPD- (<10 mmHg)); Group 2 (IASPPD+ (≥10 mmHg)). Body composition parameters were measured using bioelectrical impedance analysis. Results: In 42 (40%) patients, the simultaneously measured IASBPD was equal to or higher than 10 mmHg. The right brachial SBP was higher in 63% of patients. There were no differences between the groups in terms of demographic and clinical characteristics. Regarding the two groups' body composition parameter differences, VFA was significantly higher in group 2 (p = 0.014). Conclusions: The IASBPD is known to be associated with an increased risk of cardiovascular events. Although the body mass indexes (BMIs) of the two groups were similar, VFA levels in those with a greater than 10 mmHg IASBPD were found to be significantly higher. This finding may explain the increased cardiovascular risk in this group.

Abnormal nailfold videocapillaroscopic findings in heart failure patients with preserved ejection fraction.

BACKGROUND: Microvascular dysfunction is one of the pathophysiological mechanisms in heart failure. Nailfold videocapillaroscopy is a noninvasive technique used to examine the microvasculature. OBJECTIVE: In this study, we aimed to investigate the nailfold capillaroscopic abnormalities in heart failure patients with reduced and preserved ejection fraction and compare those with control group. METHODS: Three groups of patients were recruited for the study: HFrEF group includes the patients with heart failure with reduced ejection fraction (HFrEF), HFpEF group, patients with heart failure with preserved ejection fraction (HFpEF) and control group, healthy asymptomatic individuals. Nailfold videocapillaroscopy was performed with a videodermatoscope and all nailfold images were evaluated for enlargement and hemorrhages. RESULTS: Abnormal videocapillaroscopic findings including enlargement and/or hemorrhages were present in 7 (24%) patients in HFrEF group, 19 (66%) patients in HFpEF group and 11 (37%) in control group. The number of patients with abnormal videocapillaroscopic findings were significantly greater in HFpEF group compared to HFrEF (p < 0.05) and control groups (p < 0.05). However, no significant difference was observed in videocapillaroscopic findings between HFrEF and control groups. CONCLUSIONS: Our study showed that microvascular abnormalities demonstrated by videodermatoscopic examination of nailfold capillaries are considerably more common in HFpEF patients compared to HFrEF and control groups.

Resuscitated sudden cardiac death due to severe hypokalemia caused by teff grain herbal tea: A case report.

Obesity is a common health problem and the prevalence is increasing worldwide. The improper and unregulated use of unconventional therapies, especially herbal treatment methods, has grown due to widespread availability. In our case, a 41-year-old male patient developed palpitation, confusion, loss of consciousness, and cardiac arrest while at home. An emergency medical team was called and chest compressions were performed by his wife until the medical team arrived. Ventricular fibrillation was detected on the monitor 5 minutes after the cardiac arrest occurred and the patient was defibrillated. A physical evaluation revealed hypotension and tachycardia. Electrocardiography (ECG) showed a fast idioventricular rhythm with capture and fusion beats and evident J waves in leads DII, DIII, and aVF. Brain magnetic resonance imaging and thoracic tomography revealed no pathology to explain his clinical condition and the coronary angiography results were not significant. The laboratory parameters included potassium (K): 2.23 mEq/L, ionized K (arterial blood): 2.43 mEq/L, sodium: 142 mEq/L, calcium: 9.3 mg/dL, creatinine: 1.6 mg/dL, pH: 7.29, cardiac troponin I: 0.12 (normal range: 0-0.11 ng/mL) and creatinine kinase mass: 8.3 (normal range: 0-3.23 ng/mL). After fluids and electrolyte replacement therapy were administered, the ECG results revealed narrow QRS complex atrial fibrillation followed by a normal sinus rhythm with a 490 ms corrected QT interval. The patient was extubated in follow-up. There were no risk factors for coronary artery disease, no history of drug or other substance use, and no exposure to excessive emotional or physical stress. The patient said that he had been consuming a large quantity of teff tea for 5 days to lose weight. He was discharged without any complications and has been asymptomatic in 9 months of follow-up. The inappropriate use of weight loss alternatives, especially herbal therapies such as teff tea, and the incidence of associated side effects are increasing due to wide availability and easy access. The general population should be warned about this issue.

The effect of cardiac resynchronization therapy on arterial stiffness and central hemodynamic parameters.

INTRODUCTION: Cardiac resynchronization therapy (CRT) is a device-based method of treatment which decreases morbidity and mortality in heart failure with reduced ejection fraction (HFrEF). This study was aimed to investigate the effects of CRT on hemodynamic and arterial stiffness parameters evaluated by noninvasive method, and determine whether there is a correlation between the changes after CRT in these parameters and the clinical response to CRT or not. METHODS: The study included 46 patients with HFrEF who were planned to undergo CRT implantation. Before the CRT implantation, clinical and demographic data were recorded from all patients. Hemodynamic and arterial stiffness parameters were measured oscillometrically by an arteriograph before CRT implantation. The patients were re-evaluated minimum three months after CRT; the above-mentioned parameters were measured again and compared to the pre-CRT period. RESULTS: Compared to the period before CRT, mean systolic blood pressure (SBP) (116.8 ± 19.1 mm Hg vs 127.7 ± 20.9 mm Hg, P = .005), central SBP (cSBP) (106.2 ± 17.3 mm Hg vs 116.8 ± 18.7 mm Hg, P = .015), cardiac output (CO) (4.6 ± 0.8 lt/min vs 5.1 ± 0.8 lt/min, P = .002), stroke volume (65.6 ± 16.3 mL vs 72.0 ± 14.9 mL), and pulse wave velocity (PWV) (10 ± 1.6 m/sec vs 10.4 ± 1.8 m/sec, P = .004) increased significantly in post-CRT period. In addition, the same parameters were significantly increased post-CRT period in patients with clinical response. However, there was not any similar increase in nonresponder patients. CONCLUSION: This study demonstrated that SBP, CO, and PWV increased significantly after CRT. The modest increases in these parameters were observed to be associated with positive clinical outcomes.

Increased Demodex Density in Patients Hospitalized for Worsening Heart Failure.

Infection is an important factor leading to the exacerbation of heart failure (HF), resulting in hospitalization. Demodex species are obligatory parasites in human skin, and increased density was reported in immunocompromised patients. In this study, we aimed to investigate the Demodex density in hospitalized HF patients compared to that of healthy controls. METHODS: This study included 36 HF patients and 36 age and sex-matched healthy controls. Five standardized biopsies were taken from the face of participants and assessed for Demodex by a light microscope. RESULTS: At least one Demodex mite was detected in 20 HF patients and nine of the control group. The number of Demodex mites was significantly higher in the HF group (median 1; min. 0 and max. 10) compared to the control group (median 0; minimum. 0 and maximum. 3). Demodicidosis was positive in 14 of the HF patients. Demodicidosis was not detected in the control group. CONCLUSIONS: This study showed that Demodex positivity is more common in HF patients hospitalized for HF exacerbation. Demodicidosis should be considered in hospitalized HF patients.

Noninvasive cardiac output measurement based optimization in nonresponders of cardiac resynchronization therapy.

BACKGROUND: Cardiac resynchronization therapy (CRT) is an important and effective therapy for end-stage heart failure (HF). Nonresponse to CRT is one of the main obstacles to its application in clinical practice. Herein, we investigated the utilization of the optimization technique using noninvasive cardiac output measurement (NICOM) based Mobil-O-Graph device that measures several circulation parameters noninvasively. METHODS: Seventy-five CRT nonresponder HF patients with an implanted CRT device were included. Patients were randomized equally to 3 groups: NICOM, echocardiographic, and empirical optimization groups. After 3 months of optimization, changes in six minutes walk test (6-MWT), cardiac output (CO), left ventricular ejection fraction (LVEF), and end-systolic volume (LVESV) were measured. New York Heart Association (NYHA) class and hospitalization for HF were also determined. RESULTS: There were no statistically significant differences among the three groups in terms of demographics, baseline characteristics. In the NICOM group, the 6-MWT, LVEF, CO, and LVESV measurements showed significant improvements compared to baseline values (P < .05). There was no significant improvement in 6-MWT, LVEF, CO, NYHA class, and LVESV in Echo and Empirical groups after 3 months (P > .05). 6-MWT, CO, LVESV percentages, and hospitalization for HF were significantly different between the groups (P < .05). In post hoc analyzes, the percentages of the change in 6-MWT, CO, LVESV, and hospitalization for HF were significantly higher in the NICOM group (P < .017). CONCLUSIONS: This study suggests that Mobil-O-Graph device optimization according to CO measures does appear to have potential hemodynamic and clinical benefits in nonresponder CRT patients. Use of Mobil-O-Graph device as an option for optimization of CRT devices can be an attractive method of improving CRT outcomes.

Incidental Findings of Computed Tomography Angiography in Patients Suspected to Pulmonary Embolism; a Brief Report.

INTRODUCTION: Computed tomography pulmonary angiography (CTPA) scans are increasingly used in emergency department (ED). Therefore, the observation of incidental findings (IFs) has also increased. This study aimed to evaluate the frequency of IFs in patients who underwent CTPA. METHODS: All consecutive patients that underwent CTPA scanning for pulmonary embolism (PE) rule out between January 2017 and June 2018 were analysed. Incidental findings were divided into and reported in three categories: group 1 potentially life-threatening, group 2 required follow up, and group 3 with limited clinical significance. RESULTS: 151 cases with the mean age of 61.2 ± 17.6 years were studied (54.3% female). PE was documented in 77 cases (50.9%). 448 IFs were detected (3 IFs were found per patient). 60 (13.3%) IFs were classified as group 1, 180 (40.1%) as group 2, and 208 (46.6%) as group 3. Cardiomegaly was the most frequent finding in group 1 (n=32), followed by aortic aneurysm (n=13). In group 2, pleural effusion (n=58) and pneumonia (n=36) were the most frequent incidental findings. Lung structure changes (n=92) and thoracic bone related findings (n=43) were the most common IFs observed in group 3. CONCLUSION: IFs were detected in the majority of patients that underwent CTPA. Most of these findings do not require follow-up or treatment. However, more than 50% of cases may require further diagnostic evaluation (40.1%) or immediate treatment (13.3%).

The Effect of Mean Platelet Volume/Platelet Count Ratio on Dipper and Non-Dipper Blood Pressure Status.

Background and Objectives: The mean platelet volume (MPV) represents a possible marker of platelet activation. There is an association between the platelet count (PC) and inflammation and platelet reactivity. We assessed the association between the MPV/PC ratio and circadian alterations in blood pressure (BP). Material and Methods: One hundred and twenty subjects in total, 80 hypertensive subjects and 40 healthy subjects (controls), were enrolled in the study group. Twenty four hour ambulatory BP monitoring (ABPM) was applied to all subjects. According to ABPM results, the hypertensive subjects were separated into two groups, such as dippers (n = 40) and non-dippers (n = 40). In all subjects, the collection of venous peripheral blood samples was performed on admission for PC and MPV measurements. Results: The two groups exhibited similar clinical baseline characteristics. A significantly higher MPV/PC ratio was determined in non-dippers compared to that in dippers and normotensives. The higher MPV/PC ratio was observed in non-dippers in comparison with that in dippers and normotensives (0.046 ± 0.007 to 0.032 ± 0.004 fL/[109/L]; 0.046 ± 0.007 to 0.026 ± 0.004 fL/[109/L], p < 0.001, respectively). A receiver operating characteristic (ROC) curve analysis showed that the optimum cut-off value of the MPV/PC ratio for predicting non-dipping patterns in hypertensive patients was 0.036 (area under the curve [AUC]: 0.98, p < 0.001). According to the cut-off value, sensitivity and specificity were found to be 95% and 95%, respectively. Conclusions: The higher MPV/PC ratio was determined in non-dipper hypertensive subjects in comparison with that in dipper hypertensive subjects. An elevation of platelet activity and an increase in thrombus burden are reflected by an increase in the MPV/PC ratio. The MPV/PC ratio may underlie the increase in cardiovascular risk in non-dippers compared to that in dippers.

Isotretinoin-associated possible Kounis syndrome: A case report and a review of other cardiovascular side effects reported in the literature.

Isotretinoin is widely used in the treatment of acne vulgaris and other dermatological diseases. Numerous side effects have been reported in the literature. A myocardial bridge occurs when segments of the coronary artery create an intramyocardial tunnel. Atherosclerotic plaque formation frequently occurs in the segment proximal to a myocardial bridge. Coronary thrombus formation, which is often the cause of myocardial infarction in young patients, can be triggered by many factors. Kounis syndrome is described as acute coronary syndromes associated with allergic or hypersensitivity reactions. This article is a description of the case of a patient predisposed to the development of a thrombus by a myocardial bridge who was successfully treated for coronary thrombosis and which may represent a case of Kounis syndrome associated with isotretinoin use presented in the context of the relevant literature.

Diffuse Coronary Artery Fistula Leading to Syncope and Treated with Transcatheter Coil Occlusion and a Defibrillator: A Case Report.

OBJECTIVES: Coronary artery fistulas connecting coronary arteries to cardiac cavities are rare but clinically significant anomalies. CLINICAL PRESENTATION AND INTERVENTION: A 47-year-old male patient presented with syncope. Left ventricular dysfunction was detected on echocardiography. Extensive coronary fistulas draining into the left ventricle were found on coronary angiography. Ventricular fibrillation was induced on electrophysiology study. Because of the induction of ventricular fibrillation, extensive fistulas, and presence of other risk factors, an implantable cardioverter defibrillator was implanted. After the detection of ischemia by nuclear scanning, microcoil occlusion of the fistula was performed. CONCLUSION: The present case describes extensive fistulas complicated with fatal ventricular arrhythmias due to ischemia and left ventricle dysfunction. A cardioverter defibrillator was implanted to prevent sudden cardiac death.

Microvascular abnormalities in asymptomatic chronic smokers: A videocapillaroscopic study.

Cigarette smoking is reportedly associated with coronary, cerebral, and peripheral vascular diseases. Nailfold videocapillaroscopy is a noninvasive imaging technique used to examine the microvasculature. In this study we aim to investigate the capillaroscopic abnormalities of asymptomatic chronic smokers (N = 30), and compare findings to those of healthy nonsmokers (N = 30). Nailfold videocapillaroscopy was performed with a videodermatoscope, with images recorded at 40× magnification. Capillary morphologies were assessed as normal, enlargement, tortuosity, and microhemorrhages. Capillaroscopic abnormalities were seen in 16 (53.3%) of subjects within the smoker group and seven (23.3%) within the nonsmoker group (p < 0.05). Six smokers had only capillary enlargement; another 10 had both capillary enlargement and microhemorrhages. In comparison, enlarged capillaries and both enlarged capillaries and microhemorrhages were observed in three and four nonsmokers, respectively. In conclusion, nailfold capillaroscopic abnormalities were more common among asymptomatic chronic smokers than healthy nonsmokers, with the enlargement of nailfold capillaries being the most common abnormality. Nailfold videocapillaroscopic examination may serve as an efficient tool in determining microvascular abnormalities in asymptomatic chronic smokers not only for risk stratification purposes, but also to take the measures needed to preclude future vascular events.

Acute anterior myocardial infarction in the 36th week of pregnancy: A successful stepwise treatment approach.

Acute myocardial infarction (AMI) is associated with a high incidence of maternal and fetal complications when it develops during pregnancy or the early postpartum period. The pathophysiology involves various factors, including alterations in the vascular wall and hypercoagulability as a result of the hormonal and hemodynamic effects of pregnancy. It frequently occurs due to the development of a thrombus following a ruptured plaque. In addition, coronary artery dissection constitutes a significant cause of AMI in pregnancy. In the literature, the therapeutic approach covers a wide spectrum, ranging from conservative follow-up to percutaneous coronary intervention, urgent bypass surgery, and occasionally, thrombolytic therapy. The success rate is often low; however, maternal and fetal complications are seen more frequently during invasive interventions and bypass surgeries because of the structural changes in the coronary intima and media wall. Presently described is the case of a woman in the 36th week of pregnancy who presented with AMI. The occlusion could not be detected during the primary percutaneous intervention, and thrombolytic treatment and a stepwise percutaneous intervention were performed with a successful result.

A case of mixed drainage total anomalous pulmonary venous return in an adult patient.

Total anomalous pulmonary venous return is observed in 1.5 to 3% of congenital heart diseases. Urgent surgical intervention is required following the diagnosis, since severe heart failure is accompanied by cyanosis from the first days of life in most of the patients. This rare congenital heart disease is often managed in adulthood with surgery. Patients who survive until adulthood without a surgical intervention have a large atrial septal defect. A 36-year-old female patient was admitted with complaints of fatigability, shortness of breath, and cyanosis of the lips. Total anomalous pulmonary venous return, secundum-type atrial septal defect, ventricular septal defect, and pulmonary hypertension were diagnosed by transthoracic echocardiography and catheter angiography. After medical treatment, surgery was planned for the patient who responded to the pulmonary vasoreactivity test with iloprost.

Evaluation of inhomogeneities of repolarization in patients with psoriasis vulgaris.

INTRODUCTION: The arrhythmia potential has not been investigated adequately in psoriatic patients. In this study, we assessed the ventricular repolarization dispersion, using the Tp-e interval and the Tp-e/QT ratio, and investigated the association with inflammation. MATERIAL AND METHODS: Seventy-one psoriasis vulgaris patients and 70 age- and gender-matched healthy individuals were enrolled in the study. The severity of the disease was calculated using Psoriasis Area and Severity Index scoring. The QTd was defined as the difference between the maximum and minimum QT intervals. The Tp-e interval was defined as the interval from the peak of the T wave to the end of the T wave. The Tp-e interval was corrected for heart rate. The Tp-e/QT ratio was calculated using these measurements. RESULTS: There were no significant differences between the groups with respect to basal clinical and laboratory characteristics (p > 0.05). The Tp-e interval, the corrected Tp-e interval (cTp-e) and the Tp-e/QT ratio were also significantly higher in psoriasis patients compared to the control group (78.5 ±8.0 ms vs. 71.4 ±7.6 ms, p < 0.001, 86.3 ±13.2 ms vs. 77.6 ±9.0 ms, p < 0.001 and 0.21 ±0.02 vs. 0.19 ±0.02, p < 0.001 respectively). A significant correlation was detected between the cTp-e time and the Tp-e/QT ratio and the PASI score in the group of psoriatic patients (r = 0.51, p < 0.001; r = 0.59, p < 0.001, respectively). CONCLUSIONS: In our study, we detected a significant increase in the Tp-e interval and the Tp-e/QT ratio in patients with psoriasis vulgaris. The Tp-e interval and the Tp-e/QT ratio may be predictors for ventricular arrhythmias in patients with psoriasis vulgaris.