A very rare interarterial communication: total occlusion of right coronary artery with antegrade collateral supply from left circumflex artery through conus branch.

PURPOSE: The purpose of the present case report is to describe an extremely rare and unusual coronary interarterial communication. METHODS: A 65-year-old female patient admitted with acute coronary syndrome underwent a coronary angiography performed with Judkins technique to obtain standard angiographic views. RESULTS: We have demonstrated a very rare interarterial communication traversing an unusual retroaortic path between the body of left circumflex artery and the conus branch of the right coronary artery. CONCLUSION: Coronary interarterial communications are rarely encountered; however, may fulfill important tasks in the coronary circulation. Therefore, invasive cardiologists and cardiovascular surgeons should be aware of their presence.

Serum omentin-1 levels in hypertensive patients.

Hypertension (HT) is a disease that can cause death due to multiple target organ damage and eventually related vascular system damage. High blood pressure is known increased inflammatory activity and to cause endothelial dysfunction has been showed in HT patients. Omentin-1 is a glucoprotein of the adiponectin family released from visceral adipose tissue, endothelial cells, and visceral fat stromal-vascular cells. It has anti-inflammatory effect and circulating omentin-1 concentration correlates negatively with waist circumference, insulin resistance, and body-mass index. Serum omentin-1 is used as a biomarker of coronary artery disease, obesity, cancer, metabolic syndrome, inflammatorydisease, atherosclerosis, and diabetes mellitus. The aim of our study is to investigate circulating omentin-1 levels in HT patients compared to healthy normotensive controls. Patients diagnosed with new essential HT (n = 61) and healthy normotensive individuals (n = 60) were enrolled in this study. The HT group was separated into two subgroups. There were 30 patients in stage 2 HT group and 31 patients in stage 1 HT group. Omentin-1 levels were significantly lower both in stage 1 and 2 HT subgroup as compared with the normotensive controls (72.19 ± 54.33 ng/ml for stage 1 HT subgroup; 62.45 ± 47.01 ng/ml for stage 2 HT subgroup; and, 147.84 ± 58.55 ng/ml for healthy normotensive controls; overall P < 0.001). The present study demonstrated that serum Omentin-1 levels decreased in patients with HT compared with normotensive controls. These lower concentrations may be attributed to a combined outcome of endothelial dysfunction, renal injury, and inflammation in the setting of hypertension.

Prognostic value of thiol/disulfide homeostasis in symptomatic patients with heart failure.

We aimed to examine the role of thiol/disulphide homeostasis (TDH) in heart failure and its stages and the prognosis of heart failure. A total of 140 subjects were included in the study. Total and native thiol levels were higher in the control group compared to the patient groups (p < .001). While the average disulphide/total thiol ratio was similar in groups 1 and 2, it was found to be significantly lower in the control group compared to other groups and significantly higher in group 3 compared to other groups (p < .05). Mean native thiol and total thiol levels were found lower in patients with mortality compared to surviving patients (p < .001). In ROC curve analysis, it was determined that the total thiol level had 81.8% sensitivity and 83.1% specificity, and native thiol level had 81.8% sensitivity and 84.3% specificity. We found that TDH was impaired in favour of disulphide in cases of heart failure.

Nesfatin-1 Levels Predict Angiographic No-Reflow in Patients with ST-Segment Elevation Myocardial Infarction.

BACKGROUND: Nesfatin-1 is a novel peptide possessing pleiotropic metabolic effects. No-reflow phenomenon (NR) is a poor prognostic indicator occurring in around 30% of all patients undergoing primary percutaneous coronary interventions (pPCI). Inflammation and complexity of coronary artery disease (CAD) play pivotal roles in the pathogenesis of NR. In this study, we investigated the relationship between admission serum nesfatin-1 level, NR and complexity of CAD assessed by SYNTAX-1 (SS-1) and SYNTAX-2 (SS-2) scores in patients with ST-segment elevation myocardial infarction (STEMI) undergoing pPCI. METHODS: A total of 174 STEMI patients who underwent pPCI were included in the study and divided into NR (n = 36) and normal flow (n = 138) groups. Serum nesfatin-1 was measured by enzyme-linked immunosorbent assay. Seventy-eight consecutive age-, gender- and co-morbidity-matched patients undergoing coronary angiography with < 50% stenosis comprised the control group. RESULTS: Nesfatin-1 levels were significantly lower in the NR group compared to the normal flow and control groups (10.8 ± 6.6 ng/mL vs. 34.9 ± 24 ng/mL vs. 43.6 ± 23.2 ng/mL, respectively, p < 0.001). Nesfatin-1 was significantly and inversely correlated with SS-1 and SS-2 scores (r = -0.709 and r = -0.655, respectively, both p < 0.001). Multivariate logistic regression analysis showed that nesfatin-1 [odds ratio (OR) = 0.81, 95% confidence interval (CI) = 0.708-0.936, p = 0.004] and glomerular filtration rate (OR = 0.94, 95% CI = 0.892-0.989, p = 0.018) were independently associated with NR. In the receiver operating characteristic analysis, nesfatin-1 < 15.21 ng/mL predicted NR with 78.4% sensitivity and 72.2% specificity (area under the curve = 0.809, 95% CI = 0.701-0.918, p < 0.001). CONCLUSIONS: Admission nesfatin-1 level is a potent predictor of NR in STEMI patients undergoing pPCI. Additionally, nesfatin-1 has a robust and negative correlation with the complexity of CAD.

Wet Cupping Therapy Improves the Parameters of Ventricular Repolarization.

BACKGROUND: Cupping therapy (CT) is an ancient medical treatment since antiquity and is used for the treatment of such various disease states as contagious diseases, chronic or acute inflammatory disease, and autoimmune disorders. Ventricular repolarization is represented by QT and corrected-QT (QTc) intervals from surface electrocardiography. OBJECTIVES: As novel repolarization parameters, Tpeak-toTend (Tp-Te) interval, and Tp-Te/QT and Tp-Te/QTc ratios are suggested to correlate better with ventricular arrhythmia risk in various clinical conditions than sole QT and QTc intervals. In this study, we aimed to determine whether these parameters changed significantly after CT in healthy individuals. METHODS: One hundred and twenty participants (57 women and 63 men; mean age: 49.0 ± 13.0 years) participated in this study. ECGs strips were recorded 1 hour before and 1 hour after CT from each participant, and relevant ECG parameters were compared. RESULTS: Tp-Te interval [69.51 ± 11.54 msec vs 63.15 ± 10.89 msec, p = 0.001], Tp-Te/QT ratio [0.191 ± 0.030 vs 0.174 ± 0.031, p = 0.002] and Tp-Te/QTc ratio [0.175 ± 0.030 vs 0.159 ± 0.026, p = 0.001] were found to be significantly decreased 1 hour after the procedure compared with the pre-procedure values. However, no statistically significant change was observed in mean heart rate, QT and QTc intervals, QT/QRS and cQT/QRS, and frontal QRS/T angle after the procedure compared with the same parameters before the procedure (p > 0.05). CONCLUSIONS: In accordance with the results of our study, it is plausible to conclude that CT may exert cardioprotective effect. However, larger scale prospective studies are needed to support our findings.

Normal coronary diameters in Turkish population.

BACKGROUND: This study aims to define normal coronary artery diameters of males and females in a sample of Turkish population, compared to Asian-Indian and Western Caucasian populations. METHODS: Angiographic and demographic data of a total of 324 patients (147 males, 177 females; mean age 55.3±10.1 years; range, 32 to 82 years) who underwent elective coronary angiography with angiographically normal coronary arteries between July 2017 and March 2019 were analyzed retrospectively. Proximal diameters of major epicardial coronary arteries were measured using the Axiom Artis software according to edge detection method. All the measurements were adjusted to the body surface area. Unadjusted and adjusted values were compared between genders and with the Asian-Indian and Caucasian population samples. RESULTS: The mean diameters of unadjusted/adjusted left main coronary artery, proximal left anterior descending artery, proximal left circumflex artery, and proximal right coronary artery were 4.5±0.6 mm/2.4±0.4 mm/m2, 3.7±0.5 mm/1.9±0.3 mm/m2, 3.3±0.6 mm/1.7±0.3 mm/m2, and 3.4±0.6 mm/1.8±0.4 mm/m2, respectively. Adjusted left main coronary artery and proximal left circumflex artery were narrower, and unadjusted proximal left anterior descending artery and unadjusted/adjusted proximal right coronary artery were larger in men, compared to women in the Turkish population. Turkish population had similar body surface area and unadjusted/adjusted coronary diameters with Caucasians, whereas adjusted proximal left anterior descending artery was larger in the Turkish population than in Asian-Indians. CONCLUSION: Our study findings on the Turkish population contradict the traditional belief that women have narrower coronary arteries then men. Furthermore, the Turkish population have comparable adjusted/unadjusted coronary diameters with the Western Caucasians, but larger adjusted/unadjusted proximal left anterior descending artery, compared to Asian-Indians. We believe that our findings may contribute to the global data pool of normal coronary diameters and can be utilized in future studies as a database.

Effect of habitual cigarette smoking on the index of cardiac electrophysiological balance in apparently healthy individuals.

BACKGROUND AND AIM: Chronic cigarette smoking has been suggested to portend risk for cardiac arrhythmia generation. Index of cardiac electrophysiological balance (iCEB) is a relatively new ECG parameter indicating balance between ventricular depolarization and repolarization, thereby providing more insight concerning ventricular arrhythmogenesis (VA) than other classical ECG parameters such as QT and corrected QT (QTc) intervals. The present study aimed to assess the status of iCEB in healthy habitual smokers. METHODS: This retrospective study included a total of 80 apparently healthy subjects (45% female, mean age 39.4 ±â€¯8.1 years) with smoking habit and 82 healthy non-smoking subjects (40% female, mean age 37.0 ±â€¯8.6 years) were included between January-September 2019. Demographic, clinical and ECG characteristics were obtained from medical records. iCEB and corrected iCEB values were calculated by dividing respective QT and QTc intervals by QRS duration. RESULTS: Mean PR, QRS and QT intervals were similar between the groups, whereas mean heart rate and QTc interval were greater in the smoker group compared with the non-smokers [(82.0 ±â€¯8.9 bpm vs 77.8 ±â€¯12.4 bpm, respectively, p = 0.016) and (427.05 ±â€¯22.6 msec vs 399.9 ±â€¯12.8 msec, respectively, p < 0.001)]. Subject with smoking habit had greater iCEBc than the controls (5.10 ±â€¯0.49 vs 4.68 ±â€¯0.39, respectively, p < 0.001). However, there was no significant difference in regard of iCEB between the groups (4.37 ±â€¯0.46 vs 4.32 ±â€¯0.42, respectively, p = 0.456). CONCLUSION: iCEBc increases significantly in healthy smokers compared with non-smokers. This may suggest an increased predisposition to Torsades de Pointes-mediated VA in healthy smokers, or in chronic smokers with inherent QT-prolonging genetic variations or those on QT-prolonging drug therapy.

Relationship of growth differentiation factor-15 with aortic stiffness in essential hypertension.

AIM: We aimed to assess the relationship between echocardiographic parameters of aortic elasticity, namely aortic strain, aortic distensibility and aortic ß-index, and serum growth differentiation factor (GDF)-15 in patients with newly diagnosed essential hypertension (HT). METHODS: Grade-1 HT patients (n = 50), grade-2 HT (n = 70) patients and 35 healthy controls were included. RESULTS: GDF-15 was greater in grade-2 HT group compared with the other groups. All aortic elasticity parameters were worse in grade-2 HT group compared with the other groups. GDF-15 correlated positively with E/E' ratio (the ratio of transmitral E velocity to mean diastolic mitral annular velocity) and ß-index; and aortic strain and aortic distensibility correlated negatively with serum GDF-15. ß-index, aortic diastolic diameter and diastolic blood pressure were independently associated with GDF-15. CONCLUSION: GDF-15 may be utilized in the prediction of increased aortic stiffness.

Usefulness of white blood cell count to mean platelet volume ratio in the prediction of SYNTAX score in patients with non-ST elevation myocardial infarction.

OBJECTIVE: White blood cell (WBC) count to mean platelet volume (MPV) ratio (WMR) is associated with major adverse cardiovascular events in patients with non-ST elevation acute coronary syndrome (NSTEMI). We aimed to compare WMR between NSTEMI patients and matched-controls and to evaluate its predictive value on SYNTAX score. METHODS: Total 175 patients with NSTEMI and 160 age and co-morbidity matched subjects were recruited in our study. WMR was compared between the patient and control groups. The patient group was further subdivided into 3 tertiles according to SYNTAX scores as follows: low SYNTAX score tertile (score ≤22, 141 patients); intermediate SYNTAX score tertile (score between 23 and 32, 20 patients); and, high SYNTAX score tertile (score ≥33, 14 patients). WMR was further assessed among the tertiles. RESULTS: WMR was significantly greater in the patient group compared to the control group (p<0,001). WMR among low, intermediate and high score tertiles were calculated to be 890±26, 1090±042 and 1500±65, respectively (p <0,001). In receiver operating characteristics (ROC) analysis, WMR >960 predicted a SYNTAX score ≥23 with 80.6% sensitivity and 67.6% specificity (AUC: 0.756; 95% CI: 0.685 - 0.818; p <0.0001) and a WMR >1360 predicted a SYNTAX score ≥33 with 71.4% sensitivity and 93% specificity (AUC: 0.840; 95%CI: 0.777 - 0.892; p <0.0001). CONCLUSIONS: WMR value was significantly elevated in NSTEMI patients, compared to controls. Higher WMR was associated with greater SYNTAX score in patients with NSTEMI. WMR may be used to predict severity of the CAD and to implement risk stratification in patients with NSTEMI.

Usefulness of Tp-Te interval and Tp-Te/QT ratio in the prediction of ventricular arrhythmias and mortality in acute STEMI patients undergoing fibrinolytic therapy.

BACKGROUND AND AIM: Acute ST-elevation myocardial infarction (STEMI) is associated with fatal and non-fatal ventricular arrhythmic events (VAE). Although primary percutaneous intervention (PCI) is first-line treatment in STEMI, fibrinolytic therapy (FT) is still widely used in many countries. Tp-Te interval; Tp-Te/QT ratio and QT dispersion (QTd) are novel markers of ventricular repolarization (VR) and associate with VAE and mortality. Hereby, we assessed Tp-Te, QTd and Tp-Te/QT in acute STEMI patients undergoing FT and analyzed their relationship with post-FT VAE, and arrhythmic and overall deaths. METHODS: A total of 207 consecutive STEMI patients treated with FT were retrospectively evaluated. Patients were divided in Group 1 (non-VAE group) and Group 2 (VAE group). ECG, clinical and demographic data were noted. Relationship between the pre-FT electrocardiographic parameters of VR and post-FT VAE, arrhythmic and overall death was evaluated. RESULTS: Tp-Te, Tp-Te/QT and QTd were significantly higher in Group 2 compared to Group 1 (p < 0.05). Tp-Te, Tp-Te/QT, QTd, QTc and left ventricular ejection fraction (LVEF) predicted VAE. Tp-Te/QT and LVEF predicted arrhythmic death (1.05; 95% CI 1.01-1.08; p = 0.031 and 0.87; 95% CI 0.72-0.96; p = 0.040; respectively). In ROC analysis, cut-off for Tp-Te/QT to predict VAE was >0.305 with 87.5% sensitivity and 60.1% specificity (AUC: 0.90; 95% CI: 0.85-0.95; p < 0.001), and to predict arrhythmic death was >0.315 with 83.3% sensitivity and 62% specificity (AUC: 0.70; 95% CI: 0.60-0.81; p = 0.018). CONCLUSION: Tp-Te, Tp-Te/QT, QTc, QTd and LVEF are independent predictors of post-FT VAE in acute STEMI. Tp-Te/QT ratio is associated with VA-related deaths.

Association between Growth Differentiation Factor 15 and Non-Dipping Circadian Pattern in Patients with Newly Diagnosed Essential Hypertension.

OBJECTIVE: Non-dipper hypertension (HT) confers greater risk compared with dipper HT. Growth differentiation factor 15 (GDF-15) recently emerged as a novel and independent marker of cardiovascular disease, both in diagnostic and prognostic scopes. Our aim was to evaluate the relationship of circadian blood pressure (BP) pattern with serum GDF-15 level in newly diagnosed HT patients without left ventricular hypertrophy. SUBJECTS AND METHODS: Newly diagnosed non-dipper (n = 66) and dipper (n = 60) HT patients were selected according to 24-h ambulatory BP monitoring (ABPM). The controls comprised healthy normotensive subjects (n = 31). Data was collected through physical examination, laboratory analysis, ABPM, and echocardiography. GDF-15 was measured using ELISA. RESULTS: Greater GDF-15 level was found in the non-dippers compared with the dippers and the controls (557.53 ± 91.7, 513.79 ± 62.86, and 494.44 ± 79.30 ng/L, respectively, p < 0.001). In bivariate linear correlation analysis, GDF-15 correlated positively with glomerular filtration rate (r = 0.180, p =0.030), total cholesterol (r = 0.170, p = 0.038), septal E/E' ratio (r = 0.344, p = 0.001), lateral E/E' ratio (r = 0.366, p < 0.001), nighttime systolic BP (r = 0.166, p = 0.046), and nighttime diastolic BP (r = 0.188, p = 0.024); however, it correlated negatively with septal and lateral E' velocities (r = 0.268, p = 0.005 and r = 0.236, p = 0.013, respectively). Furthermore, GDF-15 level and nighttime diastolic BP remained independently associated with non-dipper HT. In ROC analysis, optimal cutoff value for GDF-15 was 524.6 ng/L with 56.7% sensitivity and 72.4% specificity (AUC: 0.676, 95% CI: 0.580-0.772, p < 0.05). CONCLUSION: Our results showed GDF-15 upregulation in the non-dipper HT group. GDF-15 and nighttime diastolic BP were independently associated with the non-dipping pattern. This study may suggest possible utilization of GDF-15 in the prediction of non-dipper HT.

The Effect of Lower and Higher Calorie Meal on the Parameters of Ventricular Repolarization in Healthy Subjects.

BACKGROUND: Cardiovascular modulation following meal consumption has been known. Little and conflicting data is present regarding electrocardiographic QT and QTc intervals after a meal, and status of ventricular repolarization following meal is not known comprehensively. AIM: To inquire the electrocardiographic status of ventricular repolarisation thoroughly after lower and higher calorie meal consumption in a comparative manner. METHODS: A group of 61 healthy individuals were studied before and after lunch. They were divided into two groups according to the calorie consumed (higher calorie and lower calorie; median 1580 and 900 kcals, respectively). Calorie consumed was estimated using dietary guidelines. Data was collected from 12-lead ECG both in a fasted state and 2nd postprandial hour for each participant. Parameters of ventricular repolarization, namely, JTp, Tp-e, QT, QTc intervals and their ratios, as well as RR intervals, were compared between fasted and postprandial states for every participant. RESULTS: Tp-e and QTc intervals, and Tp-e/QTc ratio do not significantly change after both higher- and lower-calorie meals. JTp and QT intervals significantly shorten in both groups, regardless of the calorie consumed. While JTp shows a positive correlation with RR interval both before and after a meal in lower calorie intake group, no correlation was found with RR interval after a meal in higher calorie group. Logistic regression analysis revealed that higher calorie intake during a meal is a predictor for greater shortening in JTp and QT, compared to lower calorie meal. CONCLUSION: Our study may guide future studies on ventricular repolarisation, particularly those conducted on various disease conditions or drug effect of cardiac electrophysiology.

The Relationship Between Serum Endocan Level and Aortic Elastic Properties in Patients With Newly Diagnosed Essential Hypertension.

Endothelial dysfunction plays role in the generation of both essential hypertension (EH) and aortic stiffness. We evaluated the relationship between serum endocan level and aortic elastic properties (AEPs) assessed with the aortic strain, aortic distensibility, and aortic stiffness index by echocardiography. Newly diagnosed EH patients (n = 67) and controls (n = 70) were included in the study. The EH group was subdivided into stage 1 and 2 EH groups. A higher endocan level was found in the EH group, compared to the controls (34.2 ± 13.0 vs 24.1 ± 7.3 ng/mL, respectively, P < .001). All the AEP parameters were worse in the EH group, compared to the controls. Further, endocan levels correlated with aortic distensibility (r = -0.305, P < .001) and aortic strain (r = -0.181, P = .038), but not with aortic stiffness index (r = 0.162, P = .064) in the whole study population. Aortic elastic properties deteriorate and serum endocan level increases in patients with EH. Moreover, serum endocan level shows a correlation with deteriorated AEPs, and hence may a surrogate marker of escalating aortic stiffness in patients with newly diagnosed EH.

Relationship between Paraoxonase-1 and Arylesterase Enzyme Activities and SYNTAX I and II Scores in Patients with ST-Elevation Myocardial Infarction.

Background: Although serum paraoxonase-1 (PON-1) and arylesterase (ARE) activities are linked to the presence of stable coronary arterial disease, their correlation with SYNTAX Score I (SS1) and SYNTAX Score II (SS2) has not been known well. Our aim was to determine the association between PON-1 and ARE activities, together with the genetic polymorphism of PON-1, and both SS1 and SS2 in patients with acute ST-segment elevation myocardial infarction (STEMI). Methods: Consecutive patients with acute STEMI (n=102: 78 male, 24 female; mean age=61.14±12.25 y) admitted to the Emergency Department of Kirsehir Ahi Evran University Hospital between August 2018 and December 2018 were enrolled. PON-1 and ARE activities were determined on hospital admission. The SS1 and SS2 scores were calculated by using the angiographic and clinical data. Subsequently, the relationships between the activities of the enzymes, together with the genetic polymorphism of PON-1, and both SS1 and SS2 were interrogated. Results: The mean SS1 and the mean SS2 were 19.8±9.7 and 32.3±11.5, respectively. The phenotype distributions of PON-1 were Q192Q (n=60), R192Q (n=35), and R192R (n=7). The respective PON-1 (U/L) and ARE (kU/L) activities were 514.85±29.34 and 216.82±36.72 in the low SS1 category; 527.60±56.31 and 203.95±55.97 in the intermediate SS1 category; and, 690.10±11.07 and 238.48±45.65 in the high SS1 category.PON-1 and ARE activities did not correlate with the SS1 categories, and varying SS2 scores. The distribution of the Q192R polymorphism was homogenous among the different SS1 and SS2 scores. The localization of acute STEMI also did not associate with the activities of either enzyme. Conclusion: Admission serum PON-1 and ARE activities, together with the PON-1 Q192R genetic polymorphism, showed association neither with SS1 and SS2 nor with the localization of infarction in our acute STEMI patients.

Changes in the parameters of ventricular repolarization during preapnea, apnea, and postapnea periods in patients with obstructive sleep apnea.

BACKGROUND: Ventricular arrhythmias are reported to be more common in patients with obstructive sleep apnea (OSA). Preliminary evidence showed such parameters regarding ventricular repolarization as Tp-e, Tp-e/QT, and Tp-e/QTc may be related with increased cardiac arrhythmias and even sudden cardiac death. The purpose of the present study was to evaluate ventricular repolarization during immediately preapnea period, apnea period, and postapnea hyperventilation period in patients with OSA. METHODS: A total of 59 patients who underwent polysomnography and were diagnosed with OSA between the years 2016-2017 in our hospital were included in our study. Of 59 patients (mean age: 52.51 ± 9.66), 28 were male and 31 were female. In all patients, Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio, together with some other parameters, were calculated. Categorical variables were expressed as proportion and continuous variables were expressed as mean ± standard deviation. Electrocardiogram calculations of interest were compared through preapnea, apnea, and postapnea periods using Friedman's test. RESULTS: Tp-e interval (85.6 ms [78.3-95.6], 98 ms [88.5-107.7], 91.2 ms [81-98.8], respectively; P < 0.001), Tp-e/QT ratio (0.219 [0.202-0.237], 0.242 [0.224-0.269], 0.233 [0.212-0.246], respectively; P < 0.001), and Tp-e/QTc ratio (0.210 [0.190-0.222], 0.233 [0.209-0.247], 0.212 [0.193-0.229], respectively; P < 0.001) were significantly increased during apnea period compared to the preapnea period and significantly decreased during postapnea hyperventilation period compared to the apnea period. CONCLUSION: Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio were shown to be increased during apnea period and decreased during postapnea hyperventilation period. Our findings may help explain cardiac arrhythmias and sudden death in OSA patients.