The association between CHA2DS2-VASc score and aortic valve sclerosis.

BACKGROUND: Antithrombotic therapy in atrial fibrillation is generally managed with the CHA2DS2-VASc score. Aortic valve sclerosis (AVS) is a focal thickening of the aortic valve without a restriction of motion. AVS is related to several cardiovascular risk factors. Our study was performed to evaluate whether the presence of AVS was associated with the CHA2DS2-VASc score. METHODS: This cross-sectional, observational study comprised 411 patients with AVS grades 1-3 [AVS (+)] and 102 patients with AVS grade 0 [AVS (-)]. We compared CHA2DS2-VASc scores between the AVS (+) and AVS (-) groups. RESULTS: We determined that the AVS (+) group had a higher CHA2DS2-VASc score than the AVS (-) group [3 (0-8) vs 1 (0-4), p < 0.001) ]. CONCLUSIONS: In our study, the CHA2DS2-VASc score was found to be higher in patients with AVS than in those without AVS. AVS may predict cardiovascular risk in the general population.

Níveis de Tiol Sérico e Homeostase Tiol/Dissulfeto em Pacientes com Doença Valvar Mitral Reumatismal e em Sujeitos Saudáveis / Serum Thiol Levels and Thiol/Disulfide Homeostasis in Patients with Rheumatic Mitral Valve Disease and Healthy Subjects

Resumo Fundamento A doença valvar mitral reumatismal (DVMR) é a apresentação mais comum das doenças cardíacas reumáticas (DCR). Os processos de inflamação e fibrose também têm papéis significativos em sua patogênese. Estudos recentes demonstram que os tióis e o tiol-dissulfeto são marcadores de stress oxidativo inéditos e promissores. Objetivos O objetivo deste estudo foi avaliar diferenças entre os níveis de tiol sérico e de tiol-dissulfeto em pacientes com DVMR e no grupo de controle. Métodos Noventa e dois pacientes com DVMR foram cadastrados no estudo. Cinquenta e quatro sujeitos saudáveis, e com correspondência de sexo e idade em relação ao grupo de estudo, também foram incluídos no estudo como um grupo de controle. Foram investigados os níveis de tiol nos pacientes com DVMR e o grupo de controle. Os p-valores menores que 0,05 foram considerados estatisticamente significativos. Resultados Os pacientes com DVMR apresentaram pressão sistólica da artéria pulmonar (PSAP) e níveis de diâmetro do átrio esquerdo (AE) mais altos que os do grupo de controle. Os níveis de tiol nativo (407±83 μmol/L vs. 297±65 μmol/L, p<0,001) e tiol total (442±82 μmol/L vs. 329±65 μmol/L, p<0,001) são mais altos no grupo de controle. Níveis de dissulfeto (16,7±4,9 μmol/L vs. 14,8±3,7 μmol/L, p=0,011) são mais altos no grupo de pacientes com DVMR. Foi identificada uma correlação positiva entre as razões dissulfeto/tiol nativo e dissulfeto/tiol total com PSAP, diâmetro de AE, e gravidade da EMi. A razão dissulfeto/tiol total é significativamente mais alta em pacientes com EMi grave que em pacientes com EMi leve a moderada. Conclusões Até onde se sabe, este é o único estudo que avaliou a homeostase tiol/dissulfeto como um preditor inédito, que está relacionado de forma mais próxima à DVMR e à gravidade da EMi.

Abstract Background Rheumatic mitral valve disease (RMVD) is the most common presentation of rheumatic heart disease (RHD). Inflammation and fibrosis processes also play significant roles in its pathogenesis. Recent studies showed that thiols and thiol-disulfide are promising novel oxidative stress markers. Objectives The present study aimed to evaluate differences in the serum thiol and thiol-disulfide levels in patients with RMVD and the control group. Methods Ninety-two patients with RMVD were enrolled in the study. Fifty-four healthy subjects, age, and gender-matched with the study group, were also included in the study as a control group. This study investigated thiol levels in patients with RMVD and the control group. P-values lower than 0.05 were considered statistically significant. Results The patients with RMVD presented higher systolic pulmonary artery pressure (SPAP) and left atrial (LA) diameter levels than the control group. Native thiol (407±83 μmol/L vs. 297±65 μmol/L, p<0.001) and total thiol (442±82 μmol/L vs. 329±65 μmol/L, p<0.001) levels were higher in the control group. Disulfide (16.7±4.9 μmol/L vs. 14.8±3.7 μmol/L, p=0.011) levels were higher in the group of patients with RMVD. A positive correlation was found between disulfide/native and disulfide/total thiols ratio with SPAP, LA diameter, and MS severity. Disulfide/total thiols ratio was significantly higher in patients with severe MS than with mild to moderate MS patients. Conclusions To the best of our knowledge, this is the only study of its kind that has evaluated thiol/disulfide homeostasis as a novel predictor, which was more closely related to RMVD and the severity of MS.

Serum Thiol Levels and Thiol/Disulfide Homeostasis in Patients with Rheumatic Mitral Valve Disease and Healthy Subjects. / Níveis de Tiol Sérico e Homeostase Tiol/Dissulfeto em Pacientes com Doença Valvar Mitral Reumatismal e em Sujeitos Saudáveis.

BACKGROUND: Rheumatic mitral valve disease (RMVD) is the most common presentation of rheumatic heart disease (RHD). Inflammation and fibrosis processes also play significant roles in its pathogenesis. Recent studies showed that thiols and thiol-disulfide are promising novel oxidative stress markers. OBJECTIVES: The present study aimed to evaluate differences in the serum thiol and thiol-disulfide levels in patients with RMVD and the control group. METHODS: Ninety-two patients with RMVD were enrolled in the study. Fifty-four healthy subjects, age, and gender-matched with the study group, were also included in the study as a control group. This study investigated thiol levels in patients with RMVD and the control group. P-values lower than 0.05 were considered statistically significant. RESULTS: The patients with RMVD presented higher systolic pulmonary artery pressure (SPAP) and left atrial (LA) diameter levels than the control group. Native thiol (407±83 µmol/L vs. 297±65 µmol/L, p<0.001) and total thiol (442±82 µmol/L vs. 329±65 µmol/L, p<0.001) levels were higher in the control group. Disulfide (16.7±4.9 µmol/L vs. 14.8±3.7 µmol/L, p=0.011) levels were higher in the group of patients with RMVD. A positive correlation was found between disulfide/native and disulfide/total thiols ratio with SPAP, LA diameter, and MS severity. Disulfide/total thiols ratio was significantly higher in patients with severe MS than with mild to moderate MS patients. CONCLUSIONS: To the best of our knowledge, this is the only study of its kind that has evaluated thiol/disulfide homeostasis as a novel predictor, which was more closely related to RMVD and the severity of MS.

FUNDAMENTO: A doença valvar mitral reumatismal (DVMR) é a apresentação mais comum das doenças cardíacas reumáticas (DCR). Os processos de inflamação e fibrose também têm papéis significativos em sua patogênese. Estudos recentes demonstram que os tióis e o tiol-dissulfeto são marcadores de stress oxidativo inéditos e promissores. OBJETIVOS: O objetivo deste estudo foi avaliar diferenças entre os níveis de tiol sérico e de tiol-dissulfeto em pacientes com DVMR e no grupo de controle. MÉTODOS: Noventa e dois pacientes com DVMR foram cadastrados no estudo. Cinquenta e quatro sujeitos saudáveis, e com correspondência de sexo e idade em relação ao grupo de estudo, também foram incluídos no estudo como um grupo de controle. Foram investigados os níveis de tiol nos pacientes com DVMR e o grupo de controle. Os p-valores menores que 0,05 foram considerados estatisticamente significativos. RESULTADOS: Os pacientes com DVMR apresentaram pressão sistólica da artéria pulmonar (PSAP) e níveis de diâmetro do átrio esquerdo (AE) mais altos que os do grupo de controle. Os níveis de tiol nativo (407±83 µmol/L vs. 297±65 µmol/L, p<0,001) e tiol total (442±82 µmol/L vs. 329±65 µmol/L, p<0,001) são mais altos no grupo de controle. Níveis de dissulfeto (16,7±4,9 µmol/L vs. 14,8±3,7 µmol/L, p=0,011) são mais altos no grupo de pacientes com DVMR. Foi identificada uma correlação positiva entre as razões dissulfeto/tiol nativo e dissulfeto/tiol total com PSAP, diâmetro de AE, e gravidade da EMi. A razão dissulfeto/tiol total é significativamente mais alta em pacientes com EMi grave que em pacientes com EMi leve a moderada. CONCLUSÕES: Até onde se sabe, este é o único estudo que avaliou a homeostase tiol/dissulfeto como um preditor inédito, que está relacionado de forma mais próxima à DVMR e à gravidade da EMi.

Transcatheter Self-Expandable Aortic Valve (Portico) Implantation in a Patient with Previous Mitral Valve Replacement: A Case Report.

Transcatheter aortic valve implantation (TAVI) has shown favorable outcomes in patients with severe symptomatic aortic valve stenosis who are at high surgical risk or who are unsuitable candidates for open-heart surgery. However, concerns exist over treating patients who have undergone previous mitral valve surgery due to the potential interference between the mitral prosthetic valve or ring and the TAVI device. In this case report, we present a case in which a patient with symptomatic severe aortic stenosis and previous mechanical mitral valve replacement was successfully treated with TAVI using a Portico valve, which is under-researched.

The role of thiol levels in predicting contrast-induced nephropathy in patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention.

OBJECTIVE: Contrast-induced nephropathy (CIN) is a common complication of diagnostic or interventional procedures that may arise from administration of intravascular contrast media. Recent studies have reported the thiol-disulfide ratio as a novel oxidative stress marker. Therefore, we investigated the role of thiol levels in predicting CIN in patients with ST-segment elevation myocardial infarction (STEMI) who had undergone primary percutaneous coronary intervention (PCI). METHODS: A total of 302 patients were enrolled in the study. CIN was defined as an increase in serum creatinine concentration ≥0.5 mg/dL compared with the admission value or a >25% relative rise during the first 48-72 hours after the procedure. To evaluate the relationship between thiol levels and CIN, the patients were divided into a CIN group and a non-CIN group. RESULTS: CIN occurred in 44 (15%) patients. Native thiol (274.8±84.7 µmol/L vs. 220.8±97.1 µmol/L, p=0.001) and total thiol (305.4±89.7 µmol/L vs. 260.1±102.1 µmol/L, p=0.009) levels were higher in patients within the non-CIN group. Disulfide (15.8±6.6 µmol/L vs. 19.6±8.4 µmol/L, p=0.002) levels, and mean disulfide/total thiol ratios (8.4±3.7 vs. 5.9±3.1, p=0.001) were higher in patients with CIN (+) group. In univariate analysis, the initial native thiol, total thiol, disulfide levels, and disulfide/total thiol ratio were found to have prognostic significance in the development of CIN. In the multivariate regression analysis, only the disulfide/total thiol ratio (OR=1.190; 95% CI: 1.090-1.300; p=0.001) was significantly and independently associated with CIN. The cutoff value of the disulfide/total thiol ratio to predict CIN on admission in patients with STEMI who underwent primary PCI was 7, with a sensitivity of 68.2% and a specificity of 79.8%. CONCLUSION: Our results suggest that thiol/disulfide homeostasis could be a good biochemical risk marker for CIN in STEMI patients who underwent primary PCI.

Percutaneous left atrial appendage closure in a patient with haemophilia and atrial fibrillation: a case report.

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is a major cause of embolic stroke. In patients with hereditary bleeding disorders such as haemophilia, management of AF particularly anticoagulation can be quite challenging. Left atrial appendage (LAA) closure is an emerging option in AF patients who are not eligible for oral anticoagulation therapy because of contraindications or high bleeding risk. CASE SUMMARY: A 67-year-old man with permanent AF and haemophilia was referred for further evaluation of our cardiology clinic by his primary haematologist. The CHA2DS2-VASc score was estimated to be 3 and the HAS-BLED score was 3. Due to high risk of bleeding, we decided to perform percutaneous LAA closure instead of oral anticoagulation. Pre-procedural cardiac computerized tomography angiography and transoesophageal echocardiography were performed for measurements of LAA dimensions and exclude LAA thrombus. Percutaneous LAA occlusion was performed using a 28-mm AmplatzerTM AmuletTM device. The final result was excellent without significant residual leak, pericardial effusion, and embolic complication. Clopidogrel 75 mg/day and aspirin 81 mg/day for 1 month with adequate FVIII prophylaxis and then only aspirin 81 mg/day for 2 months were recommended. No antiplatelet was given after 3 months. The patient did not report any thrombotic or haemorrhagic adverse events and there were no complications related to implanted device after 1 year of follow-up. DISCUSSION: In patients with hereditary bleeding disorders such as haemophilia, management of AF particularly anticoagulation can be quite challenging. In this report, we present a case of percutaneous LAA occlusion using AmplatzerTM AmuletTM device in a patient who has haemophilia and permanent AF. LAA closure has the potential to be more cost effective as compared to oral anticoagulation therapy due to lesser necessity of clotting factor infusion.

Combination of change in hematological parameters with exercise stress test to predict coronary artery disease.

OBJECTIVE: Treadmill exercise stress testing for identifying patients with a higher likelihood of coronary artery disease (CAD) before elective coronary angiography is recommended in the current guidelines. In this study, we aimed to evaluate the changes in the hematological parameters before and after exercise stress test in relation with the presence of CAD. METHODS: A total of 113 patients with chest pain who underwent treadmill exercise testing and coronary angiography were included in this study. RESULTS: Neutrophil count (4.38±0.99 vs 5.19±0.93, P<.001), and neutrophil to lymphocyte ratio (NLR) (2.04±0.63 vs 2.41±0.78, P<.001) were significantly elevated after treadmill exercise test in all the patients. Increase in the NLR after exercise test was significantly higher in patients with positive exercise test (n=68) than negative exercise test (n=45) (0.49±0.58 vs 0.19±0.44, P=.016). The sensitivity and specificity of treadmill exercise testing according to coronary angiography was 79% and 64%, respectively. A cut-off point of 0.2 for the change in the NLR in addition to positive treadmill exercise testing had 91% sensitivity and 92% specificity in predicting significant coronary artery stenosis (AUC:0.913, 95% CI: 0.805-1.000, P<.001). CONCLUSIONS: Neutrophil to lymphocyte ratio is an important inflammatory marker that can contribute to treadmill ECG testing in predicting CAD.

Comparison of echocardiographic findings in patients with nonfunctioning adrenal incidentalomas.

Adrenal incidentalomas (AIs) are usually discovered incidentally after imaging unrelated to adrenal glands. We aimed to evaluate standard risk factors for systemic atherosclerosis and echocardiographic changes in patients with nonfunctioning AIs and compare them with normal subjects. We evaluated 70 patients diagnosed with AIs and 51 healthy controls. Mean levels were determined for HbA1c, LDL, uric acid, fasting plasma insulin, HOMA, and neutrophil-to-lymphocyte ratio (NLR), and these values were found to be significantly higher in the patients than the controls. The mean left atrial diameter, interventricular septum thickness, posterior wall thickness, left ventricular mass, E-wave deceleration time, isovolumetric relaxation time, and the median ratio of the early transmittal flow velocity to the early diastolic tissue velocity (E/Em) were higher in patients with AIs compared to controls. The mitral annular early diastolic velocity was lower in patients with AIs. The mean aortic diastolic diameter, stiffness index (SI), and aortic strain were higher, and aortic distensibility was lower in the patients. The mean right ventricular diameter, right atrial major-axis diameter, and right atrial minor-axis diameter were statistically higher in the patient group than the controls. A negative correlation was found between the NLR and aortic strain and aortic distensibility, while a positive correction was found between the NLR and SI. We found altered left ventricular (LV) and right ventricular (RV) echocardiographic findings in patients with AIs without known cardiovascular disease. Aortic stiffness was also increased. These changes may be related to an increase in cardiovascular risk factors in AI patients.

The relationship between fragmented QRS and functional significance of coronary lesions.

BACKGROUND: Recently fragmented QRS (fQRS) on electrocardiography (ECG) has been introduced as a predictor of myocardial scarring and myocardial ischemia in coronary artery disease (CAD). OBJECTIVE: The aim of this study was to investigate the relationship between fQRS and fractional flow reserve (FFR) results in patients with the intermediate degree of coronary artery stenosis. METHODS: A total of 301 consecutive patients who underwent coronary angiography (CAG) and FFR measurement for intermediate coronary artery stenosis were included in the study. The study patients were divided into two groups: the low FFR group (FFR value of ≤0.80) and normal FFR (FFR value of >0.80) group. Both groups were compared in terms of the presence of fQRS. RESULTS: Of 301 patients, fQRS was detected in 128 (42.5%) and low FFR was detected in 115 (38.2%). In the low FFR group, fQRS was significantly higher (P<0.001). Multivariate analysis showed that fQRS was an independent predictor of myocardial ischemia in patients with intermediate coronary stenosis (OR=7.202, CI 95%, 4.195-12.367; p<0.001). The presence of fQRS had 70% sensitivity and 74% specificity for the prediction of FFR≤0.80. CONCLUSION: In clinical practice, the presence of fQRS on ECG is associated with myocardial ischemia in patients with intermediate coronary stenosis.

Predictive Value of Neutrophil Lymphocyte Ratio and Platelet Lymphocyte Ratio in Patients with Coronary Slow Flow.

BACKGROUND: Increased microvascular resistance due to chronic inflammation is assumed to be one of the mechanisms associated with coronary slow flow (CSF). Previous studies have shown that the platelet-to-lymphocyte ratio (PLR) and the neutrophil-lymphocyte ratio (NLR) are markers of inflammation for various diseases. In this study we aimed to evaluate the relationship between CSF and PLR-NLR. METHODS: Seventy-eight patients with CSF and 50 patients with normal coronary flow were enrolled into this study. The study subjects underwent medical examination and testing, after which their platelet-to-lymphocyte ratios and NLR values were calculated. An independent observer measured the coronary flow rate by Thrombolysis in Myocardial Infarction Frame Count (TFC) method. The platelet-to-lymphocyte ratio and NLR values were compared between the groups and correlation analysis was performed to explore the relationship between mean TFC with PLR and NLR. RESULTS: Platelet-to-lymphocyte ratio and NLR values were significantly higher in patients with CSF (p < 0.001). There was a positive significant correlation between TFC with NLR and PLR (Spearman's Rho: 0.59, p < 0.001 and Spearman's Rho: 0.30, p = 0.001, respectively). Multivariate logistic regression analysis revealed that NLR is the one independent predictor for CSF. CONCLUSIONS: This study demonstrated an association between CSF and PLR-NLR. Although the exact mechanism could not be explained, our findings support the possible role of inflammation in CSF physiopathology.

A new risk scoring model for prediction of poor coronary collateral circulation in acute non-ST-elevation myocardial infarction.

BACKGROUND: We aimed to investigate the clinical features associated with development of coronary collateral circulation (CCC) in patients with acute non-ST-elevation myocardial infarction (NSTEMI) and to develop a scoring model for predicting poor collateralization at hospital admission. METHODS: The study enrolled 224 consecutive patients with NSTEMI admitted to our coronary care unit. Patients were divided into poor (grade 0 and 1) and good (grade 2 and 3) CCC groups. RESULTS: In logistic regression analysis, presence of diabetes mellitus, total white blood cell (WBC) and neutrophil counts and neutrophil to lymphocyte ratio (NLR) were found as independent positive predictors of poor CCC, whereas older age (≥ 70 years) emerged as a negative indicator. The final scoring model was based on 5 variables which were significant at p < 0.05 level following multivariate analysis. Presence of diabetes mellitus, and elevated total WBC (≥ 7.85 × 103/µL) and neutrophil counts (≥ 6.25 × 103/µL) were assigned with 2 points; high NLR (≥ 4.5) with 1 point and older age (≥ 70 years old) with -1 point. Among 30 patients with risk score ≤ 1, 29 had good CCC (with a 97% negative predictive value). On the other hand, 139 patients had risk score ≥ 4; out of whom, 130 (with a 93.5% positive predictive value) had poor collateralization. Sensitivity and specificity of the model in predicting poor collateralization in patients with scores ≤ 1 and ≥ 4 were 99.2% (130/131) and +76.3 (29/38), respectively. CONCLUSIONS: This study represents the first prediction model for degree of coronary collateralization in patients with acute NSTEMI.

Increased mean platelet volume in rheumatic mitral stenosis: assessment of clinical and echocardiographic determinants.

BACKGROUND AND AIM: The aim of this study was to investigate mean platelet volume (MPV) in patients with rheumatic mitral stenosis (RMS) and to define the determinants of a possible platelet activation reflected as platelet volume enlargement. METHODS: Peripheral venous plasma value of MPV was measured in 84 consecutive patients (16 men, 68 women; mean age ± SD = 44 ± 13 years) with RMS who had no left atrial thrombus by transoesophageal echocardiography. The control group consisted of 32 healthy subjects (nine men, 23 women; mean age ± SD = 38 ± 7 years). RESULTS: The patients had significantly higher MPV values (mean ± SD = 10.07 ± 0.58 fL) compared to the healthy subjects (mean ± SD = 8.15 ± 0.60 fL, p < 0.001). Among many clinical and echocardiographic variables, left atrial spontaneous echo contrast-positivity (beta = 0.426, p < 0.001) and severe mitral regurgitation (beta = 0.577, p < 0.001) appeared as significant predictors of platelet enlargement in RMS in multiple linear regression analysis. CONCLUSIONS: Patients with RMS have increased platelet activity reflected as elevated MPV; and the coexistence of severe mitral regurgitation and presence of left atrial spontaneous echo contrast are determinants of this increment.

Evaluation of the relationship between epicardial fat volume and left ventricular diastolic dysfunction.

PURPOSE: The aim of the present study was to evaluate the relationship between epicardial fat tissue (EFT) volume and left ventricular diastolic function. MATERIALS AND METHODS: A total of 63 patients (29 male, 34 female, mean age 57.8 ± 10.9 years) were enrolled in the study. Multidetector computed tomography (MDCT) and 2D transthoracic echocardiography were performed in 29 patients with left ventricular diastolic dysfunction and 34 patients with normal diastolic function. EFT volume and coronary calcium score were measured by MDCT. RESULTS: Mean EFT volume was 137.2 ± 56.2 cm(3) for the whole study group. Mean EFT was 114.1 ± 46.6 cm(3) in patients with normal left ventricular diastolic function and 164.4 ± 54.9 cm(3) in those with left ventricular diastolic dysfunction (p = 0.0002). Diastolic dysfunction had no significant correlation with diabetes, hypertension, and coronary calcium scoring (p > 0.05). Also in our patient group EFT volume had no significant correlation with coronary calcium score (r = 0.148, p = 0.248). CONCLUSION: Patients with left ventricular diastolic dysfunction had significantly increased EFT volume.