Non-ST Elevation Myocardial Infarction Triggered by Subclavian Steal Syndrome.

Coronary-subclavian artery (SCA) steal syndrome is an uncommon phenomenon in which coronary flow is diverted into the SCA through the patent left internal mammary artery (LIMA) conduit due to critical subclavian stenosis. The prevalence of significant left SCA (LSCA) stenosis in patients, referred for coronary bypass surgery, has been reported to be 0.2 to 6.8%. Most patients usually present with angina pectoris, and secondary myocardial infarction is rarely reported. Herein, we present a case of coronary bypass graft in which a left anterior descending artery-LIMA graft was applied to supply the left arm due to complete LSCA occlusion. The patient was hospitalized with a diagnosis of non-ST elevation myocardial infarction.

Percutaneous intervention of sequential coronary venous graft.

We present a case with coronary bypass grafts in which venous graft was anastomosed to obtuse marginal (OM) 1 and OM2 branches sequentially. We performed percutaneous intervention to the proximal circumflex (CX), OM1, and bridging segment of the venous graft. Finally, bridging segment of the venous graft began to function as a CX body extending between the OM1 and OM2.

Impact of serum alkaline phosphatase level on coronary collateral circulation.

BACKGROUND: Serum alkaline phosphatase (ALP) level has been shown to be a prognostic factor for myocardial infarction and stroke via its promotion of vascular calcification. AIM: To investigate for the first time the correlation between serum ALP level and coronary collateral circulation (CCC) development. METHODS: A total of 356 patients with stable angina pectoris were evaluated retrospectively. Patients were classified according to ALP level and CCC grade. Rentrop 0-1 flow was defined as impaired CCC. Serum ALP > 129 mg/dL in men and > 104 mg/dL in women was defined as elevated ALP. All groups were compared statistically according to clinical, laboratory and demographic features. RESULTS: Impaired CCC was observed in 53.7% of the patients. The mean ALP level was 102.8 ± 57.9 mg/dL, and elevated ALP levels were obtained in 19.4% of cases. There was a significant correlation between ALP and CCC grade, and impaired CCC was associated with relatively higher ALP values (65.2% vs. 50.9%, p = 0.03). Multivariate regression analysis also showed a significant correlation between elevated ALP level and impaired CCC (OR 1.85, with a 95% CI 1.056-3.264; p = 0.03). CONCLUSIONS: Serum ALP is a widely avaliable unfavourable prognostic parameter in coronary heart disease. Elevated ALP levels were associated with inadequate CCC, which supports the previously reported literature concerning the negative prognostic value of ALP levels in cardiovascular settings.

Impact of serum alkaline phosphatase level on the pathophysiologic mechanism of contrast-induced nephropathy.

BACKGROUND: Contrast-induced nephropathy (CIN) accounts for 10% of all causes of hospital-acquired renal failure. It leadsto a prolonged in-hospital stay, and represents a powerful predictor of poor early and late outcomes. More than half of casesare observed after cardiovascular procedures. AIM: To determine the predictive value of the serum alkaline phosphatase (ALP) level in the development of CIN, something which has not been assessed before. METHODS: We prospectively evaluated a total of 430 patients with acute coronary syndrome. Patients were classified according to the development of CIN and both groups were compared statistically according to clinical, laboratory and demographic features, including the serum ALP level. RESULTS: CIN was observed in 20.5% of patients. Advanced age, male gender, elevated creatinine, uric acid and phosphate levels, and low glomerular filtration rate were correlated with the development of CIN. Correlation analysis also showed a significant association between the ALP level and the development of CIN (126.1 ± 144.9 vs. 97.2 ± 46.9, p = 0.004). Univariate regression analysis also showed the impact of ALP on the development of CIN (OR 1.004, 95% CI 1.001­1.007, p = 0.02). Conclusions: Our outcomes indicate a possible active role of ALP in the mechanism of CIN. An elevated ALP level may predict the development of CIN.

A case with a huge left ventricular thrombus growing over the posterior papillary muscle and chordae tendinae.

We present a case with a giant left ventricular thrombus grown over papillary muscle and chordae tendinae. The patient had declined both surgical and fibrinolytic therapy. After long-term anticoagulation therapy, regression was observed without embolic complication. Anticoagulation with warfarin may be preferred in such cases presenting with huge left ventricular thrombus encircling papillary muscle and chordae tendinae. .

Coronary-carotid artery collateral formation in Takayasu's arteritis: First reported case in the literature.

We present the first case report of coronary-carotid artery collateral formation in Takayasu's arteritis. There was a vasculitic involvement of both subclavian and carotid arteries with critical stenosis; cerebral perfusion was supported with collaterals arising from the mesenteric arteries and coronary artery. .

Is it feasible to perform coronary chronic total occlusion intervention with conventional angioplasty equipment.

OBJECTIVE: To demonstrate feasibility of coronary chronic total occlusion (CTO) procedures with conventional interventional equipment. METHODS: Ninety-five subsequent CTO patients were analyzed retrospectively. Patients who met the inclusion criteria were intervented with standard angioplasty catheters, guidewires, and balloon catheters. The procedural success rate of the interventions was discussed according to clinical and demographic characteristics of patients and equipment used for intervention. This study was carried out in Istanbul Medicine Hospital, Istanbul, Turkey between January 2007 and June 2011. RESULTS: Successful revascularization was achieved in 80% of patients, and all patients were discharged on the day after the procedure without complication. The success rate decreased to 60% in the CTOs of more than one year and approximately 90% in the shorter duration. Stent implantation was carried out in 82.9% of patients with a mean stent length of 42.7+/-21.4 mm. Occlusion duration was the major predictor of successful procedure on regression analysis (p=0.01). CONCLUSION: Coronary intervention for CTO with conventional equipment is still reasonable in the CTOs of short duration. Duration of coronary CTO over a year should be referred to a reference center where skilled operators and specialized equipment for CTOs are widely available.

Impact of emergency services and ambulance type on pain-to-balloon time in the acute myocardial infarction: an observational study.

OBJECTIVE: The objective of this study was to evaluate the role of first contact emergency departments and ambulances on transport duration, pain-to-balloon time, door-to-balloon time and first contact-to-balloon time in acute myocardial infarction (AMI) patients. METHODS: The study was a prospective and observational investigation. A total of 374 AMI patients initially admitted to primary coronary intervention (PCI) incapable centers were included in this study. Patients were classified according to initial presentation site (daily clinic, public hospital or private hospital) and transport manner (public or private ambulance). All groups were compared by the Kruskal-Wallis and Mann-Whitney U tests statistically according to their characteristics, transport duration and pain-to-balloon time. RESULTS: A majority of the patients were initially admitted to public (40.1%) or private hospitals (47.1%). The average door-to-balloon time was 45.0 ± 18.5 min and the mean pain-to-balloon time was 310.6 ± 160.8 min. Nearly half of the patients initially admitted to daily clinics were first transported to PCI-incapable centers, leading to delayed admission to PCI-capable centers and increased pain-to-balloon and first contact-to-balloon times (361.7 ± 194.5 min, p=0.01 and 279.7±158.2 min, p<0.001). Patients admitted to private hospitals experienced shorter average pain-to-balloon and first contact-to-balloon times (277.5 ± 148.6 min, p=0.01 and 157.4 ± 83.1 min, p<0.001). Patients transported by private ambulances also experienced shorter waiting times and shorter pain-to-balloon times (107.4 ± 70.4 and 270.1 ± 150.4 min, p<0.001). CONCLUSION: Physicians and healthcare professionals in first contact emergency departments and ambulance type appear to be factors in the increased pain-to-balloon time. AMI patients are often initially admitted to PCI-incapable centers, leading to delayed admission to PCI-capable centers and increased pain-to-balloon time.

Elevated red cell distribution width level predicts worse postinterventional thrombolysis in myocardial infarction flow reflecting abnormal reperfusion in acute myocardial infarction treated with a primary coronary intervention.

OBJECTIVES: Red cell distribution width (RDW), a measure of circulating erythrocyte size heterogeneity, is an established predictor of long-term prognosis and also all-cause mortality in a variety of cardiovascular settings. The correlation of RDW and reperfusion in acute myocardial infarction (AMI) has not been reported. Herein, we aimed to demonstrate the impact of an elevated RDW level on the postinterventional thrombolysis in myocardial infarction (TIMI) flow in AMI patients. METHODS: A total of 556 patients with an ST elevation AMI were evaluated retrospectively. Upon admission, the RDW level was measured with an automated complete blood count. Postinterventional TIMI flow was documented for all patients. Then, the patients were classified according to the RDW level and the TIMI flow. TIMI 0-1-2 flow was defined as abnormal reperfusion and RDW more than 14.8% was defined as elevated level. All groups were statistically compared according to the preinterventional clinical and demographic features. RESULTS: Abnormal reperfusion was observed in 26% of the patients. Advanced age, female sex, diabetes mellitus, and hypertension were correlated with TIMI flow less than 3. Elevated RDW (>14.8%) was observed in 21.9% of the patients and it was more common in patients who were older, women, and hypertensive patients. Elevated RDW was also strongly correlated with TIMI flow less than 3 (P<0.001). In addition, elevated RDW was found to be an independent predictor of abnormal reperfusion in multivariate regression analysis (odds ratio: 2.20, with a 95% confidence interval 1.012-4.569; P=0.05). CONCLUSION: An elevated RDW level on admission is associated with worse reperfusion in AMI treated with a primary coronary intervention, which could be one of the factors that may contribute toward the association between elevated RDW and long-term adverse cardiovascular outcomes and mortality.

Simple and new technique to assess left internal mammary artery function by left ventriculography : LIMA imaging with ventriculography.

The aim of this study was to demonstrate an assessment of left internal mammary artery (LIMA) patency and anatomy by standard left ventriculography, and to define a proposal for predicting LIMA function according to left ventriculography outcome. A total of 335 patients with an indication of coronary angiography were included. Standard coronary angiography and left ventriculography were performed initially. Visualization of LIMA occurred in the late phase of ventriculography and the LIMA visualization frame rate was counted for each patient. Then selective LIMA angiography was performed and LIMA diameter, LIMA course and anatomy, and subclavian artery anatomy were noted. Finally, the results of left ventriculography and LIMA angiography were compared by statistical analysis. During left ventriculography, LIMA was visualized in 96.4% of the patients. The mean LIMA visualization frame rate was 53.8 ± 17.7 and the mean LIMA diameter was 2.60 ± 0.36 mm. There was a strong correlation between LIMA visualization frame rate and LIMA diameter, LIMA course, and also asymptomatic subclavian artery disease (P < 0.001). Regression analysis showed that LIMA visualization frame rate is the major independent determinant for LIMA diameter prediction (P < 0.001); LIMA diameter, LIMA course, proximal LIMA side branch, and subclavian artery disease are the major predictors of LIMA visualization on left ventriculography (P < 0.001). LIMA patency and anatomy can be evaluated accurately with a simple method using left ventriculography. Besides direct visualization of LIMA, the visualization frame rate may constitute a reliable parameter for assessing LIMA function. A LIMA visualization frame rate of less than 50 is associated with a healthy and well-sized LIMA.

Association between preinfarction angina and coronary artery ectasia in the acute myocardial infarction.

OBJECTIVE: The objective of this study was to investigate the predictors of preinfarction angina (PA) and to show the association between PA and coronary ectasia (CE). METHODS: A total of 222 patients with acute myocardial infarction were included. All patients were treated with primary coronary intervention and interviewed by the staff physicians within 24 h of presentation after reperfusion had succeeded. The patients were classified according to the presence of PA and CE. All groups were compared statistically according to their clinicodemographic characteristics and angiographic results. Regression analysis was performed to show the predictors of PA. RESULTS: Half of the patients were defined as preinfarction angina (48.2%) and the success rate of primary coronary intervention did not differ statistically in the PA present group. More than half of the patients had multivessel disease and coronary ectasia was found in the 11.7%. The right coronary artery (RCA) was the most common localization for ectasia and 61.5% of the ectatic vessels were also infarct-related. Diabetes mellitus, hypertension and previous coronary heart disease were slightly more common in the PA present group. In the regression analysis, coronary ectasia, multivessel disease and previously diagnosed coronary artery disease were independent predictors of PA (P = 0.001, P = 0.01 and P = 0.03, respectively) CONCLUSIONS: CE is more common in patients with PA and more than half of the patients showed CE in the infarct-related vessel. CE and multivessel disease are independent predictors of PA. The success rate of primary coronary intervention in ectatic infarct-related vessels did not differ in the PA group.

What is the optimal length of stay in hospital for ST elevation myocardial infarction treated with primary percutaneous coronary intervention?

BACKGROUND: The aim of this study was to evaluate the safety and practicality of very early (within 48 h) discharge with long-term follow-up results, and to define an optimal length of stay in hospital for patients with ST elevation myocardial infarction (STEMI) according to their demographic characteristics and risk assessment. METHODS: A total of 267 patients with STEMI successfully treated with primary coronary intervention were retrospectively analyzed. Patients was divided into four groups according to length of hospitalization: 24 hours, 48 hours, 72 hours, and more than 72 hours. The groups were compared in terms of the patients' demographic and clinical characteristics, short- and long-term follow-up results, mortality, revascularization and major adverse cardiac events (MACE). RESULTS: More than two thirds of the patients were discharged within 48 hours (68.9%). No difference was observed between groups in terms of one month and one year MACE and one year restenosis. However, one month restenosis was slightly higher in the fourth group. At the end of the first year, there had been only four deaths, and these were in the third and fourth groups. There were no deaths among patients discharged within 48 hours. Killip class, left ventricular ejection fraction, multi-vessel disease and diabetes were the major determinants of length of stay in hospital. CONCLUSIONS: Very early discharge is safe and feasible and does not increase the mortality rate. Uncomplicated STEMI patients with single vessel disease could be discharged after 24 hours. Patients with multi-vessel disease classified in the low risk group could be discharged after 48 hours.

Level of Selvester QRS score is predictive of ST-segment resolution and 30-day outcomes in patients with acute myocardial infarction undergoing primary coronary intervention.

BACKGROUND: The presence of Q waves at presentation with a first acute ST-segment elevation myocardial infarction (STEMI) reflects a more advanced stage of the infarction. Resolution of ST-segment elevation indicating successful myocyte reperfusion may differ according to how far the infarction process has progressed. The Selvester QRS score measures infarct size. The purpose of this study was to evaluate the predictive value of QRS score on ST-segment resolution and 30-day clinical outcomes in patients with acute STEMI undergoing primary percutaneous coronary intervention (PCI). METHODS: We conducted a prospective cohort study in 112 consecutive patients (mean age 57 +/- 11 years, 94 men, 18 women) with first acute STEMI of <12-hour onset who underwent successful (TIMI-3 flow) primary PCI. The Selvester QRS score was estimated on the first electrocardiogram (ECG) after hospital admission. Sum of ST-segment elevation amount in millimeters was obtained immediately before angioplasty and 60 minutes after the restoration of TIMI-3 flow. The difference between 2 measurements was accepted as the amount of ST-segment resolution and expressed as summation sigmaSTR. summation sigmaSTR <50% was accepted as ECG sign of no-reflow phenomenon. Follow-up to 30-day was performed. RESULTS: The no-reflow phenomenon was more often observed in patients with high QRS score (> or = 4) than in those with low QRS score (34.4% and 6.3%, P < .001). Thirty-day composite major adverse cardiac event (MACE) rate was 14% in patients with high QRS score versus 0% in low QRS score group (P = .007). After adjusting for baseline characteristics, high QRS score remained a strong independent predictor of no-reflow (OR 4.1, 95% CI 1.5-10.7, P = .005) and MACE (OR 1.8, 95% CI 1.1-2.9, P = .011). CONCLUSIONS: The presence of high QRS score is an independent predictor of incomplete ST recovery and 30-day MACE in STEMI treated with primary PCI.

Effect of tirofiban therapy on ST segment resolution and clinical outcomes in patients with ST segment elevated acute myocardial infarction undergoing primary angioplasty.

BACKGROUND: In our study, we assessed the effect of glycoprotein (GP) IIb/IIIa receptor inhibition on microvascular flow after acute coronary occlusion using the early sum of ST segment resolution in electrocardiography. Platelets may play a major role in the dissociation of epicardial artery recanalization and tissue level reperfusion, referred to as the 'no-reflow phenomenon'. Therefore, GP IIb/IIIa receptor inhibition might improve myocardial reperfusion, distinct from its effects on epicardial patency. METHODS AND RESULTS: One hundred and fifteen patients (mean age 57.7 +/- 12.2 years, 96 males, 19 females) with < or = 12-hour acute ST segment elevation myocardial infarction who underwent successful primary percutaneous coronary intervention were retrospectively enrolled into the study. Patients were grouped according to whether they received tirofiban therapy or not. Clinical and electrocardiographic parameters were evaluated. The first sum of ST segment elevation amounts in millimeters was obtained immediately before angioplasty and the second 60 min after restoration of thrombolysis in myocardial infarction III flow. The difference between the two measurements was accepted as resolution of the sum of ST segment elevation and expressed as SigmaSTR. There were no significant differences between the groups regarding age, gender, cardiovascular risk factors, and laboratory parameters, duration from angina onset to the emergency unit, and from door to angioplasty. SigmaSTR was higher in patients who received tirofiban than in those who did not (7.2 +/- 2.8 and 4.2 +/- 2.6 mm, respectively; p < 0.001). There was a significant and positive correlation between GP IIb/IIIa inhibition and SigmaSTR (r = 0.336, p < 0.001), as well as between ejection fraction and SigmaSTR (r = 0.310, p < 0.001). GP IIb/IIIa inhibition was the only independent determinant of SigmaSTR in a multivariate linear regression model which contains 10 variables (p < 0.001). The incidence of in-hospital post-myocardial infarction refractory angina, reinfarction, and heart failure was significantly lower in the tirofiban group (p < 0.05, p < 0.05, and p < 0.05, respectively). Additionally, after 30 days, reinfarction and heart failure were lower in the tirofiban group (p < 0.05 and p < 0.05, respectively). CONCLUSIONS: It is well known that SigmaSTR determines microvascular perfusion. This study shows that GP IIb/IIIa inhibition with tirofiban is of value in preserving microvascular perfusion after restoring coronary thrombolysis in myocardial infarction III flow.

Anxiety and P wave dispersion in a healthy young population.

BACKGROUND: P wave dispersion (P(d)), defined as the difference between the maximum (P(max)) and the minimum P wave duration (P(min)), and P(max) are electrocardiographic (ECG) markers that have been used to evaluate the discontinuous propagation of sinus impulses and the prolongation of atrial conduction time. P(d) in normal subjects has been reported to be influenced by the autonomic tone, which induces changes in atrial size and the velocity of impulse propagation. However, the association between P(d) and anxiety has not been studied in normal subjects. METHODS AND RESULTS: P(max), P(min) and P(d) were measured in 726 physically and mentally healthy young male volunteers, aged 21.23 +/- 1.25 years (range 20-26). The Spielberger State-Trait Anxiety Inventory (STAI) was scored concomitantly. Blinded intra- and interobserver reproducibility of the P wave duration and P(d) measurement were evaluated, and comparison revealed a Pearson correlation coefficient of 0.87 and 0.89 for the P wave duration, and 0.93 and 0.90 for P(d), respectively (p < 0.001). P(max) and P(d) were significantly correlated with the state anxiety (STAI-1) subscale (r = 0.662, p < 0.001, and r = 0.540, p < 0.001, respectively) and the trait anxiety (STAI-2) subscale (r = 0.583, p < 0.001, and r = 0.479, p < 0.001, respectively). P(min) did not show any significant correlation with anxiety. Across 3 variables included in a multiple linear regression analysis, STAI-1 and STAI-2 were the significant independent determinants of P(max) and P(d). Beta coefficients indicated that the contribution of STAI-1 to P(max) (66.3 and 33.7%) and P(d) (65 and 35%) was much greater than that of STAI-2. CONCLUSIONS: STAI-1 and STAI-2 are associated with an increase in P(max) and P(d). The association of P(d) resulted from an augmentation of P(max). This is the first study to show the relation between P(max), P(d) and anxiety.

The role of angiotensin converting enzyme genotype in coronary artery ectasia.

Coronary artery ectasia (CAE) is characterised by irregular, diffuse, saccular, or fusiform dilatation of the coronary arteries. Although the underlying mechanisms are not fully understood, CAE is considered to be an original form of vascular remodelling in response to atherosclerosis. However, it is not clear why some patients develop CAE while most do not. Experimental data suggest that activation of the renin angiotensin system may lead to an increased inflammatory response in the vessel wall or to an activation of matrix metalloproteinases. In addition, an insertion/deletion (ID) polymorphism of angiotensin converting enzyme (ACE) has been associated with coronary vascular tone and the development of aneurysms. Accordingly, we hypothesised that the gene polymorphism of ACE may be a potential factor influencing the genesis of CAE. We retrospectively evaluated 112 patients who underwent coronary angiography. ACE ID genotype was determined in two groups of patients. Group 1 consisted of 56 patients who were found to have CAE. Group 2 consisted of 56 patients with significant coronary artery disease (CAD) (> 50% stenosis in any of the major epicardial coronary arteries or their branches) but without any evidence of coronary ectasia. Polymerase Chain Reaction (PCR) was used to detect ACE genotype. The ratio of DD genotype was found to be greater in group 1 than group in 2 (39% versus 18%, respectively, P < 0.05). When assessed according to the presence of the I allele, it was greater was greater in group 2 than in group 1 (82.1% versus 60.7%, respectively, P < 0.05). The results indicate that an ACE DD genotype may be a risk factor for CAE.