Usefulness of the SYNTAX Score II to Predict In-Hospital and Long-Term Mortality in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention.

Objectives: The prognostic significance of SYNTAX Score II (SS-II) is well-known in patients with chronic coronary syndromes. However, its predictive ability for mortality in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (p-PCI) remains unclear. Therefore, we aimed to investigate the prognostic accuracy of SS-II in STEMI patients who underwent p-PCI. Methods: A total of 743 STEMI patients treated with p-PCI were retrospectively analyzed. Study population was divided into three groups according to SS-II and defined as SS-IILOW ≤22.5 (n=245), 22.5 31 (n=255). In-hospital and long-term mortality at long-term follow-up were defined as clinical endpoints of the study. Results: The incidence of in-hospital (15% vs. 0.4% vs. 0.8%, p<0.001) and all-cause mortality (32.2% vs. 6.6% vs. 2.9%, p<0.001) were significantly higher in SS-IIHIGH group compared with the other two groups. In addition, Kaplan-Meier analysis showed statistically significantly increased incidence of death in SS-II > 31 group (P [log-rank] <0.001). SS-II >31 was defined as an independent predictor of all-cause mortality (hazard ratio 5.22 95% confidence interval 2.11-12.87 p<0.001). Area under the curve values derived from ROC analysis to evaluate the predictive accuracy of SS-II, anatomical and clinical SS, modified ACEF score, and Global Registry of Acute Coronary Events risk scores for all-cause mortality were 0.82, 0.71, 0.81, 0.82, and 0.82, respectively (p<0.001). Conclusion: SS-II has an increased predictive ability for in-hospital and long-term mortality in STEMI patients undergoing p-PCI.

Femoral or Radial Approach in Treatment of Coronary Chronic Total Occlusion: A Randomized Clinical Trial.

OBJECTIVES: The aim of this study was to compare transradial access (TRA) with transfemoral access (TFA) for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). BACKGROUND: TRA reduces the risk for vascular access complications but may make complex PCI, such as CTO PCI, more challenging. METHODS: FORT CTO (Femoral or Radial Approach in the Treatment of Coronary Chronic Total Occlusion) (NCT03265769) was a prospective, noninferiority, randomized controlled study of TRA vs TFA for CTO PCI. The primary study endpoint was procedural success, defined as technical success without any in-hospital major adverse cardiovascular events. The secondary study endpoint was major access-site complications. RESULTS: Between 2017 and 2021, 610 of 800 patients referred for CTO PCI at 4 centers were randomized to TRA (n = 305) or TFA (n = 305). Mean J-CTO (Multicenter CTO Registry in Japan) (2.1 ± 0.1 vs 2.2 ± 0.1; P = 0.279), PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) (1.3 ± 0.9 vs 1.1 ± 1.0; P = 0.058) and PROGRESS CTO complication (2.4 ± 1.8 vs 2.3 ± 1.8; P = 0.561) scores and use of the retrograde approach (11% vs 14%; P = 0.342) were similar in the TRA and TFA groups. TRA was noninferior to TFA for procedural success (84% vs 86%; P = 0.563) but had fewer access-site complications (2.0% vs 5.6%; P = 0.019). There was no difference between TFA and TRA in procedural duration, contrast volume, or radiation dose. CONCLUSIONS: TRA was noninferior to TFA for CTO PCI but had fewer access-site complications.

Long-Term Follow-Up of Patients With Isolated Side Branch Coronary Artery Disease.

The data with respect to stable coronary artery disease (SCAD) are mainly confined to main vessel disease. However, there is a lack of information and long-term outcomes regarding isolated side branch disease. This study aimed to evaluate long-term major adverse cardiac and cerebrovascular events (MACCEs) in patients with isolated side branch coronary artery disease (CAD). A total of 437 patients with isolated side branch SCAD were included. After a median follow-up of 38 months, the overall MACCE and all-cause mortality rates were 14.6% and 5.9%, respectively. Among angiographic features, 68.2% of patients had diagonal artery and 82.2% had ostial lesions. In 28.8% of patients, the vessel diameter was ≥2.75 mm. According to the American College of Cardiology lesion classification, 84.2% of patients had either class B or C lesions. Age, ostial lesions, glycated hemoglobin A1c, and neutrophil levels were independent predictors of MACCE. On the other hand, side branch location, vessel diameter, and lesion complexity did not affect outcomes. Clinical risk factors seem to have a greater impact on MACCE rather than lesion morphology. Therefore, the treatment of clinical risk factors is of paramount importance in these patients.

Incidence of atrial fibrillation and its effects on long-term follow-up outcomes in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction.

OBJECTIVE: The incidence of atrial fibrillation (AF) in patients with ST segment elevation myocardial infarction (STEMI) varies between 7% and 21%, and most of these studies were in the thrombolytic era. However, the frequency of new-onset AF during the primary percutaneous coronary intervention (PCI) period is still unclear. We aimed to investigate the frequency of new-onset AF and its effects on long-term clinical events in patients undergoing primary PCI. METHODS: A total of 1,603 patients who were diagnosed with STEMI and underwent primary PCI were included in the study. All the patients were monitored for at least 48 hours after the procedure. The primary endpoint of the study was defined as new-onset AF during hospitalization. RESULTS: The median follow-up period of our study was 44 months. New-onset AF developed in 85 (6.1%) patients. CHADs-VASc > 2, KILLIP > 2, and left atrial diameter were found to be independent predictors for the development of new-onset AF. In the AF (+) group, the all-cause and in-hospital mortality rates were found to be significantly higher. New-onset AF development in patients with STEMI was detected as an independent predictor of in-hospital mortality. CONCLUSION: In the era of primary percutaneous transluminal coronary angioplasty, new-onset AF rates were found to be lower than the literature data. In addition, new-onset AF was found to be a predictor of in-hospital mortality, and deaths occurred mostly in the early period. Therefore, close follow-up of these patients in the early period and re-evaluation in terms of AF burden when the patient becomes stable are important.

Treatment of LAD With Investment Procedure in a Patient With Failed CTO Attempt With TIMI 0 Flow.

Subintimal plaque modification to restore some antegrade flow can promote subsequent lesion recanalization (investment procedure) in cases of failed re-entry into the distal true lumen during chronic total occlusion percutaneous coronary intervention. In this case, we aimed to present a case in which TIMI 0 flow was observed in the LAD after unsuccessful PCI attempt, but was left to recover with the investment procedure and TIMI 3 flow was detected in the control angiogram. In unsuccessful PCI-CTO cases, even in the presence of TIMI 0, flow can improve in the future through an investment procedure.

Avoiding the emergence of contrast-induced acute kidney injury in acute coronary syndrome: routine hydration treatment.

BACKGROUND: Patients with acute coronary syndrome (ACS) have about a three-fold risk for developing contrast-induced acute kidney injury(CI-AKI). Investigating studies on routine hydration therapy have frequently included patients with stable coronary artery disease and high risk of CI-AKI [estimated glomerular filtration rate (eGFR) < 60 ml/min]. However, data on routine hydration treatment in non-ST segment elevation myocardial infarction (NSTEMI) patients with eGFR ≥60 ml/min are insufficient. We aimed to investigate the association between routine hydration therapy and CI-AKI development in NSTEMI patients at low risk for nephropathy. METHODS AND RESULTS: We randomly assigned a total of 401 NSTEMI patients to two groups: the routine hydration group (198 patients) and the nonhydration group (control group) (203 patients). Intravenous hydration with isotonic saline (1 ml/kg/h, 0.9% sodium chloride) was given for 3-12 h before and 24 h after contrast exposure to the hydration group. CI-AKI was defined as the increase in serum creatinine values 0.5 mg/dl or 25% between 48 and 72 h after the invasive procedures. In our study, the incidence of CI-AKI development in the routine hydration group (7.1%) was significantly lower than in the nonhydration group (14.1%) (P: 0.02). This study revealed that older age, amount of contrast media, and routine hydration were independent risk factors for developing CI-AKI (P < 0.01, P: 0.04, P < 0.01, respectively). CONCLUSION: We found that preprocedural and postprocedural intravenous hydration therapy reduces the development of CI-AKI in patients with NSTEMI at low risk for CI-AKI. We suggest administering routine hydration therapy in all ACS patients regardless of eGFR values.

The relationship between protein convertase subtilisin kexin type-9 levels and extent of coronary artery disease in patients with non-ST-elevation myocardial infarction.

BACKGROUND: Cardiovascular disease is one of the leading causes of death worldwide. According to the results of various studies, protein convertase subtilisin kexin type-9 (PCSK9) was determined as a novel risk factor for stable coronary artery disease. Few studies have investigated the relationship between PCSK9 levels and the severity of coronary artery disease in patients with acute coronary syndrome; thus, we herein aimed to investigate this relationship in patients with non-ST-elevation myocardial infarction (NSTEMI) who underwent coronary angiography. PATIENTS AND METHODS: Herein, 168 patients with NSTEMI were prospectively enrolled, and severity of atherosclerotic lesions was determined using SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX), Gensini and Jeopardy scores. Plasma PCSK9 levels, lipid parameters and C-reactive protein levels were measured after a 12-h fasting period. The relationship of PCSK9 levels and clinical and laboratory parameters of patients with their SYNTAX, Gensini and Jeopardy scores was investigated. RESULTS: Pearson correlation analysis showed a strong positive correlation between PCSK9 and the three scores (P < 0.001, r > 0.5 for all). In ROC analysis, a mid-high SYNTAX score of at least 25 was predicted with a sensitivity of 81% and a specificity of 63% when the PCSK9 level was higher than 52.8 ng/ml (area under a curve 0.76, P < 0.001). Multivariate linear regression analysis revealed that PCSK9, low-density lipoprotein cholesterol and creatinine levels were independent predictors of a high SYNTAX score. CONCLUSION: Taken together, high PCSK9 levels may be a risk factor for adverse events in patients with NSTEMI. Aggressive lipid-lowering therapies may benefit this group of patients.

Effects of ECE-1b rs213045 and rs2038089 polymorphisms on the development of contrast-induced acute kidney injury in patients with acute coronary syndrome.

OBJECTIVE: Endothelin-1 (ET-1) promotes the progression and induction of sclerotic renal changes in end-stage kidney disease. Membrane-bound endothelin-converting enzyme 1 (ECE-1) is involved in the production of ET-1. The aim of this study was to assess the effects of ECE-1b rs213045 and rs2038089 polymorphisms, which have been shown to be involved in the development of atherosclerosis, hypertension, and nephropathy, on the development of contrast-induced acute kidney injury (CI-AKI) in patients with acute coronary syndrome. METHODS: Our study included 38 patients with CI-AKI (CI-AKI[+]) and 55 patients without CI-AKI (CI-AKI[-]) who had coronary syndrome. The ECE-1b polymorphisms rs213045 and rs2038089 were assessed using real-time PCR. Serum ET-1 levels were measured by ELISA. RESULTS: The distributions of ECE-1b rs213045 and rs2038089 polymorphisms were similar between the two groups. Additionally, the serum ET-1 level did not different between the groups and was not associated with the ECE-1b polymorphisms. Peri-procedural low systolic blood pressure (SBP) was identified as a risk factor for CI-AKI development. CONCLUSION: Our findings indicate that ECE-1b rs213045 and rs2038089 polymorphisms are not associated with CI-AKI development and that peri-procedural low SBP is a risk factor for CI-AKI. However, variations in ECE-1b rs2038089 may contribute to the development of CI-AKI.

The association of neutrophil to lymphocyte ratio and TIMI frame count in primary percutaneous coronary intervention.

BACKGROUND: This study was sought to evaluate the relationship between admission neutrophil lymphocyte ratio (NLR) and estimated coronary flow by the TIMI frame count (TFC) method in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). METHODS: TFC of 262 consecutive STEMI patients were evaluated after PPCI. Admission NLR were calculated and TFC was determined after PPCI. According to admission NLR value, patients were divided in to two groups. NLR levels higher than 3.5 were defined "higher NLR" whereas lower than 3.5 were accepted as "lower NLR". RESULTS: TFC was significantly higher in patients with higher NLR (56.6±41.1 vs. 37.9±36.1, P<0.001). No-reflow phenomenon was more frequent in higher NLR group compared to lower NLR group (10.1% vs. 5.2%, P=0.001). In multivariate linear regression analysis admission NLR was an independent predictor of high TIMI frame count (B=2.24 95 % CI (1.17-3.31), P<0.001). CONCLUSIONS: Our findings suggest that admission NLR predicts coronary blood flow in means of TFC.

Correlation between Breast Arterial Calcification and the 10-year fatal cardiovascular risk by means of the SCORE Risk System.

OBJECTIVES: The aim of this study was to investigate the relationship between Breast Arterial Calcification (BAC) on mammography and the 10-year fatal Cardiovascular Disease (CVD) risk by using SCORE risk system. METHODS: The study was conducted from September 2013 to July 2014. A total of 66 women with BAC and 66 age-matched controls without BAC were analyzed. The groups were compared with respect to demographics, clinical, reproductive, laboratory parameters, and 10-year fatal CVD risk. RESULTS: The mean ages of the women in the study was 54.0 years (40-85 years). Hypertension, systolic blood pressure, levels of serum total cholesterol and the calculated SCORE risk were higher in the BAC (+) group than in the BAC (-) group (p=0.04, p=0.031, p=0.046, and p=0.038 respectively). Multivariate analysis showed that none of them was independent factor of BAC on mammograms, only the 10-year fatal CVD risk was close to being statistically significant (OR:1.17, CI:0.98-1.38, p=0.06). CONCLUSION: BAC on mammography was found to be related to the 10-year fatal CVD risk as calculated by the SCORE risk score system. Additional large-scale prospective studies are required to further assess whether BAC can be considered a useful screening tool for CVD risk prediction in women who screened for breast cancer by mammography.

Comparative performance of AnTicoagulation and Risk factors In Atrial fibrillation and Global Registry of Acute Coronary Events risk scores in predicting long-term adverse events in patients with acute myocardial infarction.

OBJECTIVE: This study is designed to evaluate the recently developed AnTicoagulation and Risk factors In Atrial fibrillation (ATRIA) risk score (RS), which determines the predisposition to thromboembolic and hemorrhagic events in atrial fibrillation, as a predictor of prognosis in patients having acute myocardial infarction (AMI), and to compare the predictive ability of ATRIA RS with GRACE RS. METHODS: We analyzed 1627 patients having AMI who underwent coronary angiography and/or percutaneous coronary intervention (PCI) between January 2011 and February 2015. The primary endpoints included all-cause mortality, non-fatal MI, and cerebrovascular events during follow-up. RESULTS: Multivariate Cox regression analysis showed that the ATRIA RS>3 was an independent predictor of major adverse cardiac events in patients with AMI [hazard ratio, 2.00, 95% confidence interval, 1.54 to 2.60, p<0,001]. The area under the curve (AUC) for ATRIA RS and GRACE RS was 0.66 and 0.67 (p<0.001, and p<0.001), respectively. We performed a pair-wise comparison of receiver operating characteristic curves,and noted the predictive value of ATRIA RS with regard to primary endpoints was similar to that of GRACE RS (By DeLong method, AUCATRIA vs. AUCGRACE z test=0.64, p=0.52). CONCLUSION: ATRIA RS may be useful in predicting prognosis in patients having AMI during long-term follow-up.

Effect of chronic toluene exposure on heart rhythm parameters.

BACKGROUND: Toluene is used extensively in various industrial processes, and an increasing number of workers are getting exposed to its vapor. Cardiac abnormalities that have been reported in association with toluene exposure (in toxic doses) are atrioventricular conduction abnormalities, sinus bradycardia, ventricular tachycardia, recurrent myocardial infarction, dilated cardiomyopathy, and coronary vasospasm. HYPOTHESIS: We aimed to investigate the effects of chronic toluene exposure on cardiac rhythm. METHODS: In this study, 40 workers in the polishing industry with more than 3 months of exposure to a mixture of organic solvents including toluene and 38 control subjects working in other fields who were matched by age, sex, smoking, habits, and living accommodation were investigated. Twelve-lead surface electrocardiogram and 24-hour Holter recordings were performed to determine QRS duration, PR duration (P and R wave interval on electrocardiograms), P wave dispersion, corrected QT dispersion, and heart rate variability parameters. RESULTS: The maximum heart rate was significantly lower in the toluene-exposed group compared to the control group (130.5 ± 15.1 vs 138.6 ± 16.0, P = 0.02). Corrected low frequency (cLF) and cLF/corrected high frequency (cHF) were also significantly lower in toluene-exposed group (43.6 ± 7.2 vs 50.7 ± 10.5, P = 0.01 and 1.4 ± 0.4 vs 2.2 ± 1.0, P < 0.01, respectively). Mean cHF, root-mean-square successive difference, and standard deviation of all five-minute NN interval means values were significantly higher in the toluene-exposed group (32.8 ± 8.1 vs 25.4 ± 8.2, P ≤ 0.01; 74.0 ± 46.1 vs 60.3 ± 59.4, P = 0.02; and 149.5 ± 77.0 vs 108.9 ± 43.2, P = 0.01, respectively). CONCLUSIONS: This study implies that chronic toluene exposure disturbs cardiac autonomy, particularly by suppressing sympathetic activity, and parasympathetic suppression also occurs with increased exposure duration. We also demonstrated that chronic toluene exposure was not associated with major cardiac arrhythmias and rhythm conduction system disorders.

Contrast-Induced Acute Kidney Injury Is Associated With Long-Term Adverse Events in Patients With Acute Coronary syndrome.

Contrast-induced acute kidney injury (CI-AKI) is associated with increased mortality, morbidity, and prolonged hospitalization. Patients with acute coronary syndrome (ACS) have a 3-fold higher risk of developing CI-AKI. The aim of our study was to evaluate the predictors of CI-AKI and long-term prognosis in patients with ACS who developed CI-AKI (1083 patients were enrolled). Contrast-induced acute kidney injury was defined as an increase of ≥0.5 mg/dL and/or an increase of ≥25% of pre-percutaneous coronary intervention (PCI) to post-PCI serum creatinine levels within 48 to 72 hours after the procedure. Primary end point was defined as all-cause mortality, myocardial infarction, and cerebrovascular event at long-term follow-up (36 ± 12 months). Contrast-induced acute kidney injury occurred in 178 (16.4%) of the 1083 patients. The primary end points were significantly high in patients with ACS who developed CI-AKI ( P < .001). The occurrence of CI-AKI was identified as an independent predictor of primary end point. Risk of CI-AKI development was more frequently seen in patients with ACS. Also, patients who developed CI-AKI have worse prognosis at long-term follow-up. Additional preventive treatment strategies need to be developed in this group of patients.

Relationship between myocardial performance index and severity of coronary artery disease in patients with non-ST-segment elevation acute coronary syndrome.

OBJECTIVES: We aimed to investigate the relationship between myocardial performance index (MPI) and severity of coronary artery disease, as assessed by the Gensini score (GS), in patients with non-ST-segment elevation myocardial infarction (NSTEMI). METHODS: Ninety patients with an initial diagnosis of NSTEMI were enrolled in our study. They were divided into tertiles according to the GS: low GS < 19; mid GS > 19 and ≤ 96; and high GS > 96. RESULTS: The low-, mid- and high-GS groups included 24, 38 and 28 patients, respectively. Clinical features such as gender distribution; body mass index (BMI); prevalence of diabetes mellitus, hypertension and hyperlipidaemia; and smoking status were similar in the three groups. MPI and isovolumic relaxation time were significantly higher in the high-GS group than in the low- and mid-GS groups (p < 0.001 and p = 0.005, respectively). Furthermore, the high-GS group had a significantly lower ejection fraction and ejection time (p = 0.01 and p < 0.001, respectively). MPI was positively correlated with the GS (r = 0.47, p < 0.001), and multivariate regression analysis showed that MPI was an independent predictor of the GS (ß = 0.358, p < 0.001). CONCLUSIONS: Patients with NSTEMI who fall within the high-risk group may be identified by means of a simple MPI measurement.

Apoptosis kinetics at reperfusion period in patients with acute ST-Segment Elevation Myocardial Infarction undergoing primary percutaneous coronary intervention and treated with thrombolytic therapy.

OBJECTIVE: To evaluate the kinetics of cardiomyocyte apoptosis in patients undergoing primary percutaneous coronary intervention and thrombolytic therapy in order to elucidate the dark side of reperfusion injury. METHODS: The prospective descriptive study was conducted at Istanbul University Cardiology Institute, Istanbul, Turkey, between June 2010 and December 2012. It comprised patients with persistent ST-segment elevation myocardial infarction who were divided into two groups. Patients in group 1 were treated with percutaneous coronary intervention, while those in group 2 received thrombolytic therapy. Cell death detection enzyme-linked immunosorbent assay kit was used for the analysis of cardiomyocyte apoptosis. Venous blood samples were collected to determine the apoptotic activity from the patients at the beginning of thrombolysis in myocardial infarction grade 3 of reperfusion in infarct-related artery according to thrombolysis in myocardial infarction classification, and after reperfusion provided at 6, 12, 24 and 72 hours. Creatine kinase, peak creatine kinase myocardial band and troponin levels were determined on admission and during 24hours of ST-segment elevation myocardial infarction . SPSS 15 was used for statistical analysis. RESULTS: There were 92 patients in the study; 48(51.6%) in group 1 and 44(48.4%) in group 2.There was no significant correlation between peak apoptotic activity levels at 72 hours of reperfusion and peak creatine kinase myocardial band (r=0.05;p=0.66) or the troponin (r=0.10;p=0.38) levels at 24 hours of ST-segment elevation myocardial infarction. Apoptotic activity levels increased at 72 hours compared to the baseline both for group 1 (p<0.001) and group 2(p<0.001). CONCLUSIONS: Reperfusion injury was not primarily related to apoptosis and it was a slowly progressive benign event in patients with ST-segment elevation myocardial infarction-acute coronary syndrome. Also, the negative impact of percutaneous coronary intervention was not available on reperfusion injury.

The value of the Clinical SYNTAX Score in predicting long-term prognosis in patients with ST-segment elevation myocardial infarction who have undergone primary percutaneous coronary intervention.

BACKGROUND: The Clinical SYNTAX Score (CSS) combines anatomical and clinical risk assessment. OBJECTIVES: This study was designed to evaluate CSS as a predictor of prognosis in patients with ST-elevation myocardial infarction (STEMI) undergoing a primary percutaneous coronary intervention (p-PCI). METHODS: We evaluated 433 patients who were diagnosed with STEMI and underwent p-PCI. CSS was calculated by multiplying the anatomically derived SYNTAX score (Sx) by the modified age, creatinine, and ejection fraction score. Patients were divided into tertiles according to the CSS: CSS(Low)≤14 (n=141), 1426 (n=148). The primary endpoints were defined as all-cause mortality, myocardial infarction, and cerebrovascular events over 15 months' follow-up. RESULTS: Primary endpoints were achieved in 9.2% of patients with CSS≤14, 12.5% of those with 1426 (P<0.001). Kaplan-Meier analysis showed that the CSS>26 group had a significantly higher incidence of primary endpoints [P (log-rank)<0.001]. CSS>26 was identified as an independent predictor for all-cause mortality, myocardial infarction, and cerebrovascular events (hazard ratio 3.58, 95% confidence interval 1.68-7.60, P=0.001). Receiver operating characteristic analysis found areas under the curve of 0.66, 0.59, and 0.64 for CSS, Sx score, and age, creatinine, and ejection fraction score (P<0.001, P=0.01, P<0.001, respectively). CONCLUSION: CSS may be better than the Sx score for predicting long-term prognosis in patients with STEMI undergoing p-PCI.