Risk factors for coronary artery disease in young patients with stable angina pectoris

Background/aim: We aimed to investigate the relationship between risk factors and the presence of coronary artery disease (CAD) in a young population with stable angina pectoris (SAP). Materials and methods: A total of571 individuals younger than 60 years old, admitted to the outpatient clinic with chest pain and referred for coronary angiography between January 2015 and December 2017, were included in the study. All clinical and biochemical parameters were documented in the hospital records. Coronary angiography of patients was monitored from records. The individuals were divided into two groups. The patient group consisted of 363 individuals with at least one-vessel stenosis of ≥70%, and the control group consisted of 208 individuals with normal coronary angiography. We compared the traditional and nontraditional risk factors of these two groups in terms of the presence of CAD. Results: Prevalence of male sex and smoking were higher in the patient group, and the prevalence of hypertension and diabetes were similar in the two groups. In the patient group, mean age, blood cholesterols, serum gamma-glutamyltransferase, hemoglobin, and white blood cell and lymphocyte levels were higher, while estimated glomerular filtration rate (eGFR), high-density lipoprotein cholesterol (HDL-C), platelets, and neutrophil/lymphocyte and platelet/lymphocyte ratios were lower. Low eGFR and HDL-C levels, older age, male sex, smoking, and high levels of low-density lipoprotein cholesterol and lymphocytes were independent risk factors for the presence of CAD in young patients. Conclusion: Contrary to studies performed in the elderly, traditional and nontraditional risk factors could not exactly predict the presence of CAD in a young population with SAP.

Heart Failure Functional Class Associated with Depression Severity But Not Anxiety Severity.

BACKGROUND: Depression and anxiety are common in heart failure (HF) patients and associated with adverse clinical outcomes. However, there are little or no published data that focuses on the relationship between these commonly observed situations and HF classes. The aim of this study was to evaluate the relationship between these psychiatric co-morbidities and HF symptom classes. As a second objective of our study, the associations between patient characteristics and depression severity were also assessed. METHODS: Our study enrolled a total of 420 HF study participants. The severity of depressive and anxiety symptoms was evaluated by Beck's depression and anxiety. The measured total scores were used to grade depression severity and anxiety as minimal/mild and moderate/severe. RESULTS: According to NYHA Functional Classification, 228 patients (51%) had class I symptoms, 101 (23%) had class II symptoms, 31 (7%) had class III symptoms, and class IV symptoms were noted in the remaining 60 patients (19%). The mean Beck's depression and anxiety scores were 12.4 ± 11.1 and 13.4 ± 9.0, respectively. While no association between HF symptom classes and anxiety severity was observed, a significant positive relation between HF symptom class and depression score was found. CONCLUSIONS: The results of our study suggested that HF symptom class was positively associated with severity of depression. On the other hand, there was no association between HF symptom class and anxiety score in a wide population of heart failure patients. KEY WORDS: Anxiety; Depression; Heart failure.

The association of red cell distribution width with in-stent restenosis in patients with stable coronary artery disease.

Increased red cell distribution width (RDW) is closely related to the poor prognosis and adverse events of cardiovascular diseases. We aimed to investigate the association of serum RDW levels and in-stent restenosis (ISR) after coronary stenting with bare-metal stent in patients with stable coronary artery disease. A total of 251 patients (age 62 ± 11 years, 69% male) with a history of coronary stenting who underwent control coronary angiography (128 with ISR and 123 without ISR) were enrolled into the study. Laboratory parameters were measured before angiography. ISR was defined as luminal stenosis ≥50% within the stent or within 5 mm of its edges by the quantitative coronary analysis. The patients were divided into the two groups: ISR group and no-ISR group. Baseline characteristics of the patients were similar. The ISR group had significantly higher RDW levels compared with patients in no-ISR group (14.47 ± 1.37 vs. 13.59 ± 0.88, p < 0.001). Furthermore, the ISR group had significantly longer stent length and lower stent diameter when compared to no-ISR group (p = 0.001 and p = 0.004, respectively). In a multivariate analysis, RDW levels >13.75%, high-sensitivity C-reactive protein levels, stent diameter and stent length were independently associated with ISR [odds ratio (OR) = 2.12, 95% confidence interval (CI) = 1.71-3.15, OR = 2.80, 95% CI = (1.34-4.61), OR = -2.60, 95% CI = -(1.19-4.51), OR = 2.02, 95% CI = 1.99-3.76, p = 0.001, respectively]. We concluded that increased serum RDW levels were independently associated with bare-metal ISR in patients with stable coronary artery disease.

Increased epicardial adipose tissue thickness is linked to aortic stiffness in patients with primary hypertension.

AIMS: In patients with hypertension (HT), increased aortic stiffness is related to higher cardiovascular morbidity and mortality. Recent investigations have shown that epicardial adipose tissue (EAT) is a new potential cardiometabolic risk factor. The aim of our study was to examine the relation between echocardiographically measured EAT thickness and aortic stiffness in patients with primary HT. METHODS: The study included 144 newly diagnosed and untreated essential hypertensive outpatients. Transthoracic echocardiographic EAT thickness and aortic stiffness measurements were performed for all study participants. Afterwards patients were divided in two groups according to their median EAT thickness values. The patients with EAT thickness of < 7 mm were included in group 1 and patients with EAT thickness of ≥ 7 mm were included in group 2. RESULTS: Aortic strain and distensibility parameters of group 2 were lower than in group 1. The aortic stiffness index of group 2 was found to be higher than group 1. Multivariate regression analysis revealed that EAT thickness was the only independent variable for all three parameters of aortic stiffness index, aortic strain and aortic distensibility. CONCLUSION: In patients with newly diagnosed primary HT, increased EAT thickness was significantly linked to impaired aortic elastic properties independently of other conventional adiposity measurements.

[Relation between epicardial adipose tissue thickness and blood pressure levels in prehypertension]. / Prehipertansiyonda epikardiyal yag dokusu kalinligi ile kan basinci düzeyleri arasindaki iliski.

OBJECTIVES: Increased epicardial adipose tissue (EAT) thickness is a risk factor for cardiovascular diseases. Previous studies have demonstrated that EAT thickness is increased in patients with hypertension compared with normotensive individuals. In the current study, we aimed to evaluate whether echocardiographically measured EAT thickness differs among patients with normotension, prehypertension, hypertension, and the relation between EAT thickness and blood pressure levels in prehypertensives. STUDY DESIGN: Patients with prehypertension (n=50) and hypertension (n=50) and normotensive healthy subjects (n=50) according to the American Hypertension Guidelines (Joint National Committee 7) were enrolled in the study. All participants underwent transthoracic echocardiographic examination. EAT thickness was measured from the parasternal long-axis view at end-systole. RESULTS: Compared with normotensives, EAT thickness was significantly increased in subjects with prehypertension and hypertension (4.1±1.1 mm, 5.4±1.3 mm and 6.6±1.5 mm, respectively, p<0.001). After adjustment for confounding factors like age, gender, high-density lipoprotein, waist circumference, and body mass index, EAT thickness in the normotensive, prehypertensive and hypertensive groups was measured as 4.3±1.2 mm, 5.3±1.2 mm and 6.4±1.4 mm, respectively (p=0.001). In the prehypertensive group, multivariable linear regression analysis showed that EAT thickness was positively correlated with both systolic (r=0.305, p=0.001) and diastolic (r=0.297, p=0.001) blood pressures, independent of other risk factors. CONCLUSION: In addition to hypertensive subjects, echocardiographically measured EAT thickness is increased in prehypertensive patients when compared with normotensive subjects, independent of other factors. Additionally, increased EAT thickness is significantly correlated with systolic and diastolic blood pressure levels in patients with prehypertension.

Relationship between uric acid to albumin ratio and saphenous vein graft disease in patients with coronary artery bypass graft.

OBJECTIVE: Saphenous vein graft disease (SVGD) remains a challenging issue for patients with coronary artery bypass grafting (CABG). It is associated with poor outcomes and atherosclerosis is the major cause of SVGD. Uric acid to albumin ratio (UAR) is a new marker which associated with cardiovascular mortality. We aim to evaluate the relationship between the SVGD and UAR. METHODS: We retrospectively enrolled 237 patients who underwent elective coronary angiography (CAG) for stable angina or positive stress test results >1 year after CABG. The patients were divided into two groups; SVGD (+) patients and SVGD (-) patients. The SVGD was defined as presence of at least 50% stenosis in at least 1 SVG. RESULTS: UAR were significantly higher in the SVGD (+) group (P < 0.001). Similarly, Hs-CRP, white blood cell count, and neutrophil count were significantly higher in SVGD (+) group (P = 0.03, P = 0.027 P = 0.01, respectively). In multivariate logistic regression analysis, time interval after CABG [OR = 1.161, 95% confidence interval (CI) 1.078-1.250; P < 0.001] and UAR (OR = 2.691, 95% CI 1.121-6.459; P < 0.001) were found to be independent predictors of SVGD. CONCLUSION: Our results suggested that UAR could be a simple and available marker to predict SVGD in patients with CABG who underwent elective percutaneous coronary intervention.

The Roles of Pre-P-wave Versus Peri-P-wave Fractionated Electrograms for Atrial Substrate Beyond Entrainment Response.

Atrial tachycardia (AT) with alternating cycle lengths is sparsely reported, and, hence, the ideal mapping strategy has not been firmly established. Beyond the entrainment during tachycardia, some fragmentation characteristics might also give important clues for its possible participation in the macro-re-entrant circuit. We discuss a patient with prior atrial septal defect surgical closures who presented with dual macro-re-entrant ATs related to a fragmented area on the right atrial free wall (240 ms) and the cavotricuspid isthmus (260 ms), respectively. After ablation of the fastest AT on the lateral right atrial free wall, the cycle of the first AT changed to the second AT that was interrupted on cavotricuspid isthmus, proving the dual tachycardia mechanism. This case report addresses the utilization of electroanatomic mapping information as well as fractionated electrogram timing with respect to the surface P-wave as guides for ablation location.

Thrombolytic treatment of simultaneous pulmonary embolism and impending paradoxical embolism through a patent foramen ovale: a different thrombolytic regimen.

A 72 year-old woman was admitted with a one-week history of weakness, right limb pain and progressive breathlessness. Her blood pressure was 60/40 mmHg, ECG showed inverted T waves in the precordial leads and incomplete right bundle branch block (RBBB). Transthoracic echocardiography revealed a large serpentine mobile mass across the atrial septum and mitrale valve extending into the left ventricular cavity. The right ventricle was dilated and peak systolic tricuspid annular velocity (RV-Sm) was 6.5 cm/sn, indicate right ventricular systolic function was severely depressed. Transoesophageal echocardiography showed a large, mobile thrombus in the foramen ovale, extending into the left atrium and ventricle. As the patient was in a haemodynamically compromised condition, high dose rapid infusion of streptokinase was administered. However, the thrombus did not fully resolve with this intervention. Therefore, low dose continuous streptokinase infusion was administered for an additional 72 h resulting in full resolution of the lesion by the third day of therapy. The optimal management of impending paradoxical embolism remains unclear. Prolonged continuous thrombolytic infusion may be a option for patients who do not experience full resolution of high risk thrombi with conventional thrombolytic therapy.

Mitral annular calcification and its severity predict high risk for cardio-embolic stroke in elderly patients with first diagnosed atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia worldwide and a large proportion of patients with AF are older than 75 years of age. Mitral annular calcification (MAC), which is usually observed in advanced age, is associated with increased risk of AF and cardio-embolic stroke in the general population. OBJECTIVES: This study was performed to assess whether presence of MAC and its severity predict cardio-embolic stroke in elderly patients with first diagnosed AF. METHODS: In this cross-sectional study, 72 elderly patients suffering from acute cardio-embolic stroke with first diagnosed AF and 79 elderly control group patients with first diagnosed AF and without stroke were investigated. A parasternal short-axis view at the level of the mitral annulus was used for MAC measurements. The severity of MAC was measured from the anterior to posterior edge at its greatest width. RESULTS: MAC thicknesses were significantly higher in the stroke group. ROC curve analysis showed that a cut point of 2.5 mm for the value of MAC thickness exhibited 68.1% sensitivity and 77.2% specificity for detecting cardio-embolic stroke in elderly patients with AF. In multivariate logistic regression analysis, MAC thickness (OR = 1.173, 95% CI 1.083-1.270; p < 0.001) was found to be independent predictor of cardio-embolic stroke in elderly patients with AF. CONCLUSION: MAC thickness may provide useful information for the relevant risk evaluation of elderly patients with AF. Pre-stroke MAC presence and its severity appear to have better clinical value for predicting cardio-embolic stroke in elderly patients with AF, independent from traditional risk factors for stroke.

CHA2DS2-Vasc score and saphenous vein graft disease in patients with coronary artery bypass graft surgery.

BACKGROUND: Saphenous vein grafts (SVGs) are still frequently used in coronary artery bypass graft surgery (CABG). However, the patency rate of SVGs is lower than arterial grafts. CHA2DS2-VASc score gives important information about the prognosis of various cardiovascular diseases. In this study, we aimed to investigate the association between CHA2DS2-VASc score and saphenous vein graft disease (SVGD) in patients with history of CABG surgery. METHODS: A total of 241 patients who had undergone CABG surgery and who underwent coronary angiography due to stable angina pectoris symptoms were reviewed retrospectively. SVGD was defined as ≥50% stenosis in at least one SVG. Patients were divided into two groups according to the presence or absence of SVGD. RESULTS: It was found that CHA2DS2-VASc scores were significantly higher in SVGD group. In multivariate logistic regression analysis, time interval after CABG [odds ratio (OR) = 1.077, 95% confidence interval (CI) 1.004-1.155; P = 0.037], and CHA2DS2-VASc score ≥ 4 (OR = 10.10, 95% CI 4.739-21.276; P < 0.001) were found to be independent predictors of SVGD. CONCLUSION: For the first time, our results have suggested that CHA2DS2-VASc score, which is commonly used in daily clinical practice and easy to calculate, can provide useful information for the risk assessment of patients with SVGs.

Relationship between mild renal dysfunction and coronary artery disease in young patients with stable angina pectoris.

Aim: We investigated the relationship between mild renal dysfunction (MRD) and the presence of coronary artery disease (CAD) in people under 60 years of age. Materials & methods: A total of 634 (317 patients with vessel stenosis ≥50% and 317 with normal angiography) individuals diagnosed with stable angina pectoris and estimated glomerular filtration rate (eGFR) ≥60 ml/min/1.73 m2 were included in the present study. Results: The mean eGFR was lower (95.3 ± 23.7 vs 109.7 ± 22.3, respectively, p = 0.002) and the number of patients with MRD was higher in patients with CAD (137, 43.2%) than in the control group (52, 16.4%, p < 0.001). The multivariate analysis showed that lower eGFR is an independent risk factor for presence of CAD in people under 60 years of age with stable angina pectoris. Conclusion: According to our retrospective study, the risk of developing CAD appears to be slightly increased in individuals under 60 years of age with MRD.

The Relationship Between Lymphocyte-to-Monocyte Ratio and Bare-Metal Stent In-Stent Restenosis in Patients With Stable Coronary Artery Disease.

In-stent restenosis (ISR) is a common clinical problem in patients with coronary artery disease treated with percutaneous coronary intervention. Inflammatory process plays a pivotal role in the development of ISR. Both lymphocytes and monocytes are associated with inflammatory status. Recently, it has been shown that the lymphocyte-to-monocyte ratio (LMR) is a novel inflammatory marker. We aimed to investigate the association of serum LMR levels and ISR in patients undergoing bare-metal stent (BMS) implantation. The study included 273 patients (aged 61 ± 11 years, 66.5% men) with a history of BMS implantation and a further control coronary angiography due to stable angina pectoris. Patients were divided into 2 groups: patients with and without ISR. The LMR levels were significantly lower in patients with ISR than in those without ISR (2.50 ± 0.95 vs 3.87 ± 1.51, respectively, P < .001). On multivariate logistic regression analysis, the LMR was independently associated with ISR (odds ratio [OR]: 0.310, 95% confidence interval: 0.166-0.579, P < .001) together with high-sensitivity C-reactive protein (OR: 1.244, P = .008), reason for stent implantation (OR: 6.566, P = .003), stent diameter (OR: 0.015, P < .001), and stent length (OR: 1.137, P = .007). In conclusion, LMR levels are inversely related to ISR in patients treated with BMS implantation.

Uric Acid is a Useful Tool to Predict Contrast-Induced Nephropathy.

Developing contrast-induced nephropathy (CIN) after primary percutaneous coronary intervention (pPCI) has a negative impact on survival and morbidity. We assessed the predictive value of serum uric acid (SUA) for the development of CIN in patients with ST-segment elevation myocardial infarction (STEMI) who underwent pPCI. Contrast-induced nephropathy was defined an increase of ≥25% or ≥0.5 mg/dL in creatinine concentrations within 72 hours after pPCI. Patients were divided into 2 groups according to admission median SUA level. Serum uric acid level was <5.4 mg/dL (group 1; n = 222) and ≥5.4 mg/dL (group 2; n = 228). Compared to group 1, development of CIN (12% vs 20%, P < .001) was significantly greater in group 2. Using a cut point of >5.45 mg/dL, the SUA level predicted development of CIN with a sensitivity of 70% and specificity of 67%. In multiple logistic regression analysis, SUA level, diabetes mellitus, left ventricular ejection fraction <50%, contrast volume, estimated glomerular filtration rate, and C-reactive protein level emerged as independent predictors of CIN. In conclusion, elevated SUA is an independent risk factor for the development of CIN after pPCI in patients with STEMI.

Impact of free thyroxine levels and other clinical factors on bare metal stent restenosis.

OBJECTIVE: Thyroid hormones have both direct and indirect effects on thermogenesis such as modulating vascular smooth muscle cell proliferation. However, the influence of more subtle changes in thyroid hormones on coronary atherosclerosis remains a matter of speculation. Smooth muscle cells play a crucial role in the pathogenesis of in-stent restenosis (ISR). However, the relationship between free thyroxine (fT4) and ISR has not been studied. In the present study, we aimed to assess the role of preprocedural serum fT4 level on the development of ISR in patients undergoing coronary bare metal stent (BMS) implantation. MATERIALS AND METHODS: We enrolled and analyzed clinical, biochemical, and angiographic data from 705 consecutive patients without a history of primary thyroid disease [mean age 60.3 ± 9.3 years, 505 (72%) male]; all patients had undergone BMS implantation and further control coronary angiography owing to stable or unstable angina pectoris. Patients were divided into 3 tertiles based on preprocedural serum fT4 levels. RESULTS: ISR was observed in 53 (23%) patients in the lowest tertile, 82 (35%) patients in the second tertile, and 107 (46%) patients in the highest fT4 tertile (p < 0.001). Using multiple logistic regression analysis, five characteristics emerged as independent predictors of ISR: diabetes mellitus, smoking, HDL-cholesterol, stent length, and preprocedural serum fT4 level. In receiver operating characteristics curve analysis, fT4 level > 1.23 mg/dL had 70% sensitivity and 73% specificity (AUC: 0.75, p < 0.001) in predicting ISR. CONCLUSION: Higher preprocedural serum fT4 is a powerful and independent predictor of BMS restenosis in patients with stable and unstable angina pectoris.

Atrial electromechanical delay analysed by tissue Doppler echocardiography is prolonged in patients with generalised anxiety disorders.

BACKGROUND: It has been shown that psychological status is associated with the likelihood of atrial fibrillation (AF). Prolongation of the duration of atrial electromechanical delay (AEMD) is known to be a precursor for AF development. AIM: Therefore, we aimed to evaluate AEMD in patients with anxiety disorder. METHODS: In this prospective study, a total of 82 anxiety disorder and 80 healthy subjects were enrolled. Symptoms of anxiety were evaluated by using the Hamilton Anxiety Rating Scale (HAM-A). P-wave dispersion (PWD) was measured on a 12-lead electrocardiogram. Both intra- and inter-AEMD were measured with tissue Doppler imaging. RESULTS: Basal characteristics were similar between the two groups. PWD, inter- and right intra-AEMD were significantly prolonged in patients with anxiety disorders, compared to the control group (p < 0.05). In the correlation analysis, HAM-A was significantly and moderately correlated with right intra- and inter-AEMD, and PWD. CONCLUSIONS: Patients suffering from anxiety disorders are characterised by prolonged AEMD, which can provide significant contributions to evaluate the risk for AF development in this group.

The relationship between lymphocyte-to-monocyte ratio and saphenous vein graft patency in patients with coronary artery bypass graft.

AIM: A lower lymphocyte count and a high monocyte count give important clues about the prognosis of various cardiovascular diseases. We hypothesized that lymphocyte-to-monocyte ratio (LMR) was associated with the saphenous vein graft disease (SVGD) in patients with coronary artery bypass graft (CABG). PATIENTS & METHODS: A total of 218 patients with previous history of CABG surgery, who underwent coronary angiography due to stable angina symptoms, were investigated, retrospectively. RESULTS: LMR levels were significantly lower in the SVGD group. Multiple logistic regression analyses showed that LMR levels were independent predictors of SVGD (OR: 0.648; 95% CI: 0.469-0.894; p = 0.008). CONCLUSION: Our results suggested that LMR levels may provide useful information for the relevant risk evaluation of SVGD in CABG patients.

Dynamic Systolic Compression of the Left Anterior Descending Coronary Artery by a Postinfarction Dyskinetic Left Ventricular Aneurysm.

Dynamic systolic compression of the coronary arteries is almost always due to the existence of myocardial bridging that is most commonly localized in the middle segment of the left anterior descending coronary artery. However, it has rarely been reported in patients with pericardial adhesions, tumor, foreign body, or pseudoaneurysms. Only rare case reports exist regarding dynamic coronary compression by a dyskinetic left ventricular aneurysm. We present a patient with a myocardial bridge-like systolic compression of the distal left anterior descending caused by postinfarction dyskinetic left ventricular aneurysm.