Original Article--Value of Pathological Q Waves and Angiographic Collateral Grade in Patients Undergoing Coronary Chronic Total Occlusion Recanalization: Cardiac Magnetic Resonance Study.

BACKGROUND/AIM: Successful coronary chronic total occlusion (CTO) revascularization was found by many studies to be associated with improved left ventricular (LV) systolic function and survival if evidence of viability is present. Little is known about the association of CTO revascularization in patients with electrocardiographic Q waves and improvement in angina burden as a measurement of health-related quality of life (HRQOL) afterwards. METHODS: In this study, 100 patients with single vessel CTO were included. Myocardial viability was tested by late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) and 50 patients showed evidence of viability. Seattle Angina Questionnaire (SAQ) scores were used as a measure of HRQOL. RESULTS: Pathological Q waves were present in 48 patients (including 19 patients with viable CTO territory) out of 100 patients. Patients with Q waves tended to have worse Seattle Angina Questionnaire (SAQ) scores compared to those with no Q waves (31.2 ± 11.7 vs 45.3 ± 13.9 respectively, p = 0.002), worse LV systolic function and wall motion score index (WMSI) on CMR. They also had significantly less prevalence of viability (p < 0.001). Patients with Q waves and positive viability had lower SAQ scores (37.2 ± 10.1 vs 52.7 ± 13.2 respectively, p = 0.02), higher LVEF and lower WMSI. They also had well developed collateral grade (2.1 ± 1.03 vs 0.7 ± 0.82 respectively, p < 0.001). After successful percutaneous coronary intervention (PCI), in the viable LV group, presence of Q waves was not associated with better LV functional recovery, while those with higher collateral grades were more likely to have better LV functional recovery post CTO-PCI. Patients with Q waves and viable CTO territory showed significantly better SAQ scores compared to pre-PCI (87.3 ± 12.2 vs 37.2 ± 10.1 respectively, p < 0.001). For angina frequency, post-PCI score was 80.2 ± 7.9 compared to 39.2 ± 7.1 before PCI, p < 0.001). Multivariate regression analysis showed that pathological Q waves, Rentrop's collateral grade and the Canadian Cardiovascular Society (CCS) angina class before PCI were the most significant independent predictors of improved HRQOL as reflected by SAQ (OR for Q waves 7.83, 95% CI 1.62-18.91,p 0.003), (OR for Rentrop's collateral grade 8.31,95% CI 2.21-26.33, p < 0.001), (OR for CCS class 8.39, 95% CI 1.21-20.8, p 0.01). CONCLUSION: Well-developed collateral circulation could independently predict LV functional recovery after CTO-PCI. Patients with Q waves and viable CTO territory tend to have higher CCS class before revascularization and get significant improvement of HRQOL after PCI. Other predictors of improved HRQOL are Rentrop's collateral grade and worse CCS class before PCI.

Relationship between quality of coronary collateral and myocardial viability in chronic total occlusion: a magnetic resonance study.

Revascularization of chronic total occlusion (CTO) is still debated regarding its indications and therapeutic benefits. Guidelines recommend patient selection based on ischemia detection and viability assessment. We aimed to investigate the relationship between the quality of coronary collaterals (CC), graded by Rentrop classification, and myocardial viability assessed by cardiovascular magnetic resonance (CMR). Unselected 100 consecutive patients with a single CTO were prospectively enrolled. CC of Rentrop grade two or three were considered as well-developed. Analyzing late gadolinium enhancement (LGE) images, CTO territories with mean segmental transmural scar extent < 50% were considered viable. Of the 100 patients (70 male, mean age 58.0 ± 6 years), 73 patients (73%) had angiographically visible CC. Based on LGE, patients were classified into viable (n = 50) and non-viable (n = 50) groups. Significant differences between both groups existed regarding frequency of diabetes mellitus (p = 0.044), frequency of congestive heart failure (p = 0.032), presence of pathological Q in CTO territory (p = 0.039); and presence of well-developed CC (p < 0.001). Binary logistic regression and receiver operating characteristic curve showed that presence of well-developed CC could independently (OR 9.4, 95% CI: 2.6-33.6, p < 0.001) predict myocardial viability with a sensitivity and a specificity of 72% and 74%, respectively (AUC: 0.796, 95% CI: 0.708-0.884, P < 0.001). The presence of well-developed CC could independently predict with high accuracy myocardial viability assessed by LGE in territories subtended by CTO vessels. Therefore, search for viable myocardium using different imaging modalities, e.g. CMR, may be recommended in CTO patients with well-developed CC.

Relationship between sclerostin and coronary tortuosity in postmenopausal females with non-obstructive coronary artery disease.

BACKGROUND: Coronary tortuosity (CT) is commonly encountered in postmenopausal females and is usually present without obstructive lesions. Circulating sclerostin levels are elevated in postmenopausal females. In view of sclerostin's vasculoprotective effect, we aimed to find possible association between circulating sclerostin and CT. METHOD: We prospectively enrolled 273 consecutive postmenopausal females with non-obstructive coronary artery disease diagnosed by coronary angiography. Presence and severity (by tortuosity score) of CT as well as serum sclerostin levels were assessed for each patient. RESULTS: Patients with CT (128, 47% of study group) were significantly older (P < 0.001), with higher prevalence of hypertension (P = 0.001) and had significantly higher levels of both sclerostin (P < 0.001) and hs-CRP (P = 0.001). Multivariate binary logistic regression revealed that the presence of CT (dependent variable) was associated with high sclerostin level (OR 8.9, 95% CI: 4.9-16.2, P < 0.001). Using ROC curve analysis, Sclerostin at a cut-off value of >650 pg/ml was found to be associated with presence of CT (AUC 0.69, 95% CI: 0.61-0.75, P < 0.001) with sensitivity and specificity of 75% and 72.4%, respectively. Using Pearson's correlation analysis, significant positive correlation between sclerostin and severity of CT was found (r = 0.29, P = 0.001). CONCLUSION: High circulating sclerostin is associated with the presence and severity of CT in postmenopausal females. This may add to the literature on the incompletely understood pathogenesis of CT.

What is the association between left ventricular diastolic dysfunction and 6-minute walk test in hypertensive patients?

Heart failure (HF) is a major health problem. Hypertension is an important cause of HF. Most hypertensive patients have some degree of left ventricular (LV) diastolic dysfunction. The 6-minute walk test (6MWT) provides objective data about the exercise tolerance. We aimed to find the association between the degree of LV diastolic dysfunction and the functional capacity assessed by 6MWT in hypertensive patients. The study included 200 asymptomatic hypertensive patients. All patients had undergone full history taking, complete clinical examination, electrocardiography, echocardiography for assessment of LV dimensions, systolic and diastolic dysfunction, and 6MWT. Patients were classified into two groups according to the presence or absence of LV diastolic dysfunction. Clinical and echocardiographic data were comparable between the two groups. Regarding 6MWT, at the end of the test, patients with diastolic dysfunction had significantly higher systolic (P = .0088) and diastolic (P = .019) blood pressure and higher Borg score for dyspnea (P < .00001). The distant walked and percentage of the distance to predicted value were significantly lower in patients with diastolic dysfunction (P = .0322 and .0002, respectively). Incidence of abnormal 6MWT was significantly higher in patients with diastolic dysfunction (P = .00041). Compared to patients with grades I and II, patients with grade III diastolic dysfunction had significantly higher Borg score (P = .013), lower distance walked (P = .039), and lower percentage of distance to predicted vale (P = .009). Independent predictors for abnormal 6MWT were as follows: E/E' ≥15 (P = .0022), E'/A' <1 (P = .0081), and deceleration time of E-wave <160 (P = .013). The presence of LV diastolic dysfunction in hypertensive patients has a bad effect on 6MWT. The degree of LV diastolic dysfunction was correlated with 6MWT results. It may be important to investigate LV diastolic function in asymptomatic hypertensive patients.

Symptom-to-balloon time and myocardial blush grade are predictors of left ventricular remodelling after successful primary percutaneous coronary intervention.

INTRODUCTION: In patients with ST-segment elevation myocardial infarction (STEMI), successful primary percutaneous coronary intervention (PCI) was found to be useful in earlier restoration of TIMI flow 3. However, the incidence of left ventricular (LV) dilatation and remodelling after successful primary PCI is still high. We aimed to determine the independent predictors of LV remodelling after successful primary PCI for patients with first STEMI. METHODS: We included 232 STEMI patients treated with primary PCI. Echocardiography was done on the day of PCI and after six months. LV remodelling was defined as ≥ 20% increase in the six-month left ventricular end-diastolic volume (LVEDV). RESULTS: In patients with remodelling, symptom-to-door and symptom-to-balloon times were significantly longer (p < 0.00001 for each), initial ejection fraction (EF) was significantly lower (p = 0.044), six-month LVEDV, left ventricular end-systolic volume (LVESV) and LVEDV increase were significantly higher, and EF was significantly lower (p < 0.00001 for each). Mean myocardial blush grade (MBG) was significantly lower in patients with remodelling (p < 0.00001). There was a significant positive correlation between LVEDV increase and both symptom-to-balloon time (r = 0.603, p < 0.00001) and symptom-to-door time (r = 0.564, p < 0.00001), and a significant negative correlation between LVEDV increase and MBG (r = -0.447, p < 0.00001). Logistic regression showed that the independent predictors of LV remodelling were symptom-to-balloon time (p = 0.00068), symptom to door time (p = 0.0013) and MBG (p = 0.0057). CONCLUSION: Symptom-to-door time, symptom-to-balloon time and MBG were the only significant predictors of LV remodelling.

CRUSADE bleeding score as a predictor of bleeding events in patients with acute coronary syndrome in Zagazig University Hospital.

AIM: To examine the value of CRUSADE bleeding score in predicting bleeding events in our local patients with acute coronary syndrome (ACS) in Zagazig University Hospitals. METHODS: Our study included 240 patients with ACS. They underwent history and clinical examination; 12-lead electrocardiography; echocardiography; troponin I, hematocrit value; estimated glomerular filtration rate (eGFR); application of CRUSADE score; and follow-up of the hospital stay and documentations of events. Patients were classified into two groups: Group I: patients with major bleeding, and Group II: patients without major bleeding. RESULTS: Patients with major bleeding were significantly older, with more diabetic and hypertensive patients, more prior vascular disease, heart failure, and less patients with unstable angina, higher heart rate and systolic blood, lower eGFR, and higher CRUSADE risk score. CRUSADE bleeding score was the strongest predictor of major bleeding. Sensitivity of CRUSADE score ≥33 in prediction of major bleeding in the whole study group was 80%, specificity was 73.4%, positive predictive value was 26.9%, negative predictive value was 96.9%, overall accuracy was 74.1%. Sensitivity of CRUSADE score ≥38.5 in prediction of major bleeding in the STEMI patients was 70%, specificity was 84.8%, positive predictive value was 50%, negative predictive value was 92.9%, and overall accuracy was 82.1%. CONCLUSION: CRUSADE score is a good predictor for major bleeding in Egyptian patients with ACS. It is applicable in UA/NSTEMI as well as in STEMI patients and in women as well as in men.

Stent for Life Initiative placed at the forefront in Egypt 2011.

AIMS: Myocardial infarction is a medical emergency in which 25 to 35% of patients will die before receiving medical attention. The Stent for Life registry was launched to access the current situation of the Egyptian population presenting with STEMI, and to determine what were the barriers to providing patients with cardiac problems appropriate care. METHODS AND RESULTS: This registry was conducted at 14 centres covered all the Egyptian regions including 1,324 consecutive patients presenting with STEMI during the period between January 1st, 2011 to November, 2011. Fourteen centres and 38 interventionalists participated in this registry; only six centres are Pilot Centres (fulfilling the criteria for a primary PCI centre) and were assigned at the end of 2011. Cardiovascular risk factors were mainly smoking (60.5%), dyslipidaemia (46.0%), diabetes (51.4%) and hypertension (56.0%). The mean age at presentation was 56.01±10.61years and 75.0% were male. Only 5% of the STEMI patients arrived via the emergency medical system. Thrombus aspiration was done in 42.7% of patients in primary PCI group and 25.9% in rescue PCI group. Bare metal stents (BMS) were used in 80.7% of the stented patients while drug eluting stents (DES) were used in 19.3% of the stented patients. In-hospital mortality was 2.9% (1.4% in primary PCI group, 1.1% in patients treated with thrombolysis and 0.4% in patients receiving no reperfusion therapy). CONCLUSION: Despite the logistical difficulties, excellent outcomes for acute interventional reperfusion strategy in STEMI can be achieved in our country, possibly similar to those seen in the West. There is a strong need for making the practice of PCI in STEMI more widespread in developing regions.

Our experience of controlling diabetes in the peri-operative period of patients who underwent cardiac surgery.

AIMS: We have different protocols applied in our cardiac center for control of blood glucose (BG), we like to see which protocol can achieve our goal. METHODS: From a prospective study of 120 diabetic patients randomly assigned to either simple sliding scale or Braithwaite protocol who underwent open heart surgical procedures between 2005 and 2008. The study group included 80 patients treated with Braithwaite protocol; the control group included 40 patients treated with simple sliding scale in an attempt to maintain BG level less than 200 mg/dl. RESULTS: In the study group all the patients were under 200 mg/dl at the end of 48 h postoperatively, which was not achieved in the control group (P<0.01). There was a significant reduction in hospital stay in the study group compared to the control group (mean in days 9.1+/-2.3/12.3+/-7.6) (P<0.001) and also there was no wound infection compared to the control group (0/5 cases). CONCLUSION: The study showed that control of DM in peri-operative period using Braithwaite regimen was of great benefit and safety.