Ahmet Ekmekçi

The relationship between γ-glutamyl transferase levels and the clinical outcomes in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

ObjectivesSerum &ggr;-glutamyl transferase (GGT) activity has been shown to be related to the development of atherosclerosis and cardiovascular events. The aim of this study was to evaluate the prognostic value of GGT in patients with ST-segment elevation myocardial infarction (STEMI) undergoing a primary percutaneous coronary intervention (PCI). Patients and methodsA total of 683 consecutive patients with STEMI who underwent primary PCI were evaluated. The study population was divided into tertiles on the basis of admission GGT values. A high GGT (n=221) was defined as a value in the upper third tertile (GGT>37) and a low GGT (n=462) was defined as any value in the lower two tertiles (GGT⩽37). The mean follow-up time was 29 months. ResultsThe in-hospital mortality rate was significantly higher in patients in the high GGT group (7.2 vs. 1.7%, P<0.001), as was the rate of adverse outcomes in patients with high GGT levels. In multivariate analyses, a significant association was found between high GGT levels and adjusted risk of in-hospital cardiovascular mortality (odds ratio=8.6, 95% confidence interval: 2.3–32.4, P=0.001). In a receiver operating characteristic curve analysis, a GGT value greater than 37 was identified as an effective cutoff point in STEMI for in-hospital cardiovascular mortality (area under curve=0.71, 95% confidence interval: 0.59–0.82, P<0.001). There were no differences in the long-term adverse outcome rates between the two groups. ConclusionGGT is a readily available clinical laboratory value associated with in-hospital adverse outcomes in patients with STEMI who undergo primary PCI. However, there was no association with long-term mortality.

Hematoma complicating permanent pacemaker implantation: the role of periprocedural antiplatelet or anticoagulant therapy.

BACKGROUND Periprocedural management of antiplatelet or anticoagulant therapy at the time of device implantation remains controversial. METHODS We reviewed all cases for whom a pacemaker was implanted in our institution between January 2008 and June 2009. In addition, beginning in June 2009, we prospectively collected data from all patients admitted to our institution, for whom a pacemaker was placed. Clinical characteristics and anticoagulant/antiplatelet drug use were evaluated. RESULTS A total of 574 patients underwent a permanent pacemaker implantation. Of these, 20 patients (3.6%, 9 women) experienced a hematoma on pacemaker pocket site. Patients were aged between 35 and 79 years (mean 60.6 ± 12 years). The frequency of hematoma formation was significantly higher (p<0.001) in those who used warfarin than in those who did not. Aspirin (ASA), clopidogrel, dual antiplatelet therapy (DAT), and bridging to low-molecular-weight heparin (LMWH) did not increase the risk of hematoma formation (p>0.05). Eleven pocket revisions for hematoma evacuation were needed in 9 patients (1.6%), six of whom were on warfarin therapy (p>0.05). Co-morbidities were similar in patients with and without hematoma (p>0.05). CONCLUSION The frequency of hematoma is within acceptable ranges after pacemaker placement. The use of warfarin seriously increases the risk of hematoma. Bridging to LMWH safely prevents thromboembolism.

Can the T-peak to T-end interval be a predictor of mortality in patients with ST-elevation myocardial infarction?

BackgroundThe interval between the peak and the end of the T wave (Tp–e interval) on 12-lead ECG is a measure of transmural dispersion of repolarization and may be related to malignant ventricular arrhythmias. The objective of this study was to investigate whether the Tp–e interval predicts in-hospital and long-term mortality in patients with ST-segment elevation myocardial infarction (STEMI) undergoing a primary percutaneous coronary intervention (pPCI). MethodsThis study included 488 consecutive patients with STEMI treated with pPCI. Electrocardiograms were obtained after pPCI and the Tp–e interval was measured in leads without ST-segment elevation. ResultsThere were 46 (9.4%) deaths in the population, with a mean follow-up time of 21.1±10.2 months. The Tp–e interval was associated with not only in-hospital ventricular tachycardia/fibrillation, target vessel revascularization, and death but also long-term target vessel revascularization and death. Furthermore, the Tp–e interval measured using the tail method was found to be a significant predictor of long-term mortality in multivariable Cox analyses [odds ratio 1.018, 95% confidence interval (1.004–1.033)]. Findings were similar in the Tp–e interval and the heart rate-corrected Tp–e interval (cTp–e). ConclusionTp–e and cTp–e measured using the tail method were found to be predictors of both in-hospital and long-term mortality.

Impact of admission blood glucose levels on prognosis of elderly patients with ST elevation myocardial infarction treated by primary percutaneous coronary intervention

Objective Admission hyperglycemia in acute myocardial infarction (MI) is related with increased in-hospital and long term mortality and major cardiac adverse events. We aimed to investigate how admission hyperglycemia affects the short and long term outcomes in elderly patients (> 65 years) after primary percutaneous coronary intervention for ST elevation myocardial infarction. Methods We retrospectively analyzed 677 consecutive elderly patients (mean age 72.2 ± 5.4). Patients were divided into two groups according to admission blood glucose levels. Group 1: low glucose group (LLG), glucose < 168 mg/dL; and Group 2: high glucose group (HGG), glucose > 168 mg/dL. Results In-hospital, long term mortality and in-hospital major adverse cardiac events were higher in the high admission blood glucose group (P < 0.001). Multivariate regression analysis showed: Killip > 1, post-thrombolysis in MI < 3 and admission blood glucose levels were independent predictors of in-hospital adverse cardiac events (P < 0.001). Conclusions Admission hyperglycemia in elderly patients presented with ST elevation myocardial infarction is an independent predictor of in-hospital major adverse cardiac events and is associated with in-hospital and long term mortality.

Pacemaker implantation complication rates in elderly and young patients

Aims To evaluate the complication rate differences between elderly and younger patients who receive a permanent pacemaker implantation. Methods We reviewed all cases admitted to our institution between January 2008 and June 2009 with symptomatic bradyarrhythmia for whom a permanent pacemaker was implanted. Beginning in June 2009, we prospectively collected data from all patients with the same diagnosis and procedure. The frequency of complications due to the pacemaker implantation procedure was evaluated and compared between young (<70 years old) and elderly (≥70 years old) patients. Results Among 574 patients with a permanent pacemaker, 259 patients (45.1%) were below and 315 patients (54.9%) were above or at 70 years of age. There were 240 (92.7%) and 19 (7.3%) dual-chamber pacemaker (DDD) and single-chamber pacemaker (VVI) implanted patients in the younger group, and 291 (76.8%) and 73 (23.2%) DDD and VVI pacemaker implanted patients in the elderly group, respectively. The complication rate was 39 (15.1%) out of 259 young patients and 24 (7.6%) out of 315 elderly patients. Postprocedural complications were statistically lower in the elderly patients than in younger patients (P = 0.005). Conclusion A pacemaker implantation performed by an experienced operator is a safe procedure for patients of advanced age. The patients who are above 70 years old may have less complication rates than the younger patients.

Tachycardia-induced cardiomyopathy due to repetitive monomorphic ventricular ectopy in association with isolated left ventricular non-compaction : online article - case report

Isolated left ventricular non-compaction is a rare genetic disorder manifesting mainly with heart failure, ventricular arrhythmias and systemic embolism. Isolated ventricular tachycardia originating from the right ventricular outflow tract is an arrhythmia that can be treated medically and/or by radiofrequency catheter ablation. Here, we report a case of an asymptomatic 16-year-old boy with a new diagnosis of dilated cardiomyopathy, left ventricular noncompaction and right ventricular outflow tract tachycardia. Electrophysiological studies and radiofrequency ablation of the right ventricular outflow tract tachycardia resulted in normalisation of left ventricular systolic function. This is the first case reporting left ventricular non-compaction in association with tachycardia-induced cardiomyopathy secondary to repetitive monomorphic right ventricular outflow tract tachycardia.

Presence of early repolarization on admission electrocardiography is associated with long-term mortality and MACE in patients with STEMI undergoing primary percutaneous intervention

BACKGROUND Early repolarization (ER) is associated with increased risk of sudden cardiac death and ventricular fibrillation (VF) in patients with/without structural heart disease. In this trial we examined the short- and long-term prognostic value of ER on admission electrocardiogram (ECG) in patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). METHOD Consecutive 521 patients with acute STEMI who underwent primary PCI were enrolled prospectively. Twelve-lead ECGs obtained during the initial diagnosis were scanned and stored digitally. The leads showing the typical ST segment elevation due to the acute infarction were excluded and the remaining ECG leads were included in the analysis for the presence of ER. RESULTS The study group included 61 STEMI patients (55 male; mean age 57.6±12.6 years) with ER and 460 STEMI patients (378 male; mean age 57.1±12.5) without ER on ECG. In the ER group, 14 patients (22.9%) had notching, 10 patients (16.4%) had slurring, and 37 patients (60.7%) had only J-point elevation. When analyzing regional leads, ER was observed mostly in inferior leads (n=40, 65.6%). During the hospitalization period, ventricular tachycardia or VF occurred more frequently in the ER group (19.6% vs. 10.9%; p=0.04) and 6 patients (6.9%) from the ER group and 14 patients (3%) from the control group died (p=0.01). During a follow-up period of 21.1±10.2 months, mortality was significantly higher in the ER group (12.7% vs. 4.2%; p=0.01). When total mortality rates were considered, highest mortality was observed in patients with notching pattern (5/14 subjects; 35.7%) when compared to patients with slurring (3/10 subjects; 30%), patients with only J-point elevation patterns (5/37subjects; 13.5%) and the control group (33/460 subjects; 7.1%). Presence of notching and slurring pattern on admission ECG was found as independent predictors of long-term mortality; whereas presence of only J-point elevation was not. CONCLUSION Presence of ER pattern in admission ECG in patients with STEMI is associated with both in-hospital and long-term mortality.

Altered diastolic function and aortic stiffness in Alzheimer’s disease

Background Alzheimer’s disease (AD) is closely linked to cardiovascular risk factors. Methods Echocardiographic studies were performed, including left ventricular diastolic functions, left and right atrial conduction times, and arterial stiffness parameters, namely stiffness index, pressure-strain elastic modulus, and distensibility, on 29 patients with AD and 24 age-matched individuals with normal cognitive function. Results The peak mitral flow velocity of the early rapid filling wave (E) was lower, and the peak velocity of the late filling wave caused by atrial contraction (A), deceleration time of peak E velocity, and isovolumetric relaxation time were higher in the AD group. The early myocardial peak (Ea) velocity was significantly lower in AD patients, whereas the late diastolic (Aa) velocity and E/Ea ratio were similar between the two groups. In Alzheimer patients, stiffness index and pressure-strain elastic modulus were higher, and distensibility was significantly lower in the AD group compared to the control. Interatrial electromechanical delay was significantly longer in the AD group. Conclusion Our findings suggest that patients with AD are more likely to have diastolic dysfunction, higher atrial conduction times, and increased arterial stiffness compared to the controls of same sex and similar age.

Comparison of Cockcroft-Gault and Modification of Diet in Renal Disease Formulas as Predictors of Cardiovascular Outcomes in Patients With Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

We prospectively assessed the value of estimated glomerular filtration rate (eGFR) by the Modification of Diet in Renal Disease (MDRD) and Cockcroft-Gault (C-G) equations in predicting inhospital adverse outcomes after primary coronary intervention for acute ST-segment elevation myocardial infarction. We classified 647 patients into 3 categories according to eGFR, <60, 60 to 90, and >90 mL/min/1.73 m2. The eGFRC-G classified 17 patients in the >90 mL/min/1.73 m2 subgroup and 6 and 11 patients in the 60 to 90 and <60 mL/min/1.73 m2 subgroups, respectively. In multivariate analysis, patients with eGFRC-G < 60 mL/min/1.73 m2 had 19.5-fold (95% confidence interval [CI] 1.55-178) higher mortality risk and 5.48-fold (95% CI 1.75-24.21) higher major adverse cardiac events risk compared to patients with eGFRC-G >90 mL/min/1.73 m2 (P = .01 and P = .01, respectively); the eGFRMDRD was not predictive. Although the MDRD equation more accurately estimates GFR in certain populations, the CG formula may be a better predictor of adverse events.

Presence of Metabolic Syndrome is not an Independent Predictor of In-hospital Adverse Events in Patients with ST Elevation Myocardial Infarction that Underwent Primary Percutaneous Coronary Intervention

Background: Presence of Metabolic Syndrome (MetS) has been shown to predict higher risk for cardiovascular diseases. However, in patients with ST Segment Elevation Myocardial Infarction (STEMI), prognostic importance of MetS has not been widely studied. Methods: We prospectively recruited 611 STEMI patients (521 male, 90 female) who were treated by primary angioplasty. Metabolic syndrome was diagnosed according to the International Diabetes Federation metabolic syndrome worldwide definition. Coronary angiographic data and in-hospital events of individuals were recorded. Major Adverse Cardiac Events (MACE) included cardiac death, recurrent myocardial infarction and target lesion revascularization. Results: Metabolic syndrome group included 276 (45.1% of the study cohort; mean age 56.8 ± 12.2; 210 male) and control group included 335 subjects (54.9% of the study cohort; mean age 55.6 ± 12.9; 311 male). The frequency of female gender, hypertension, Diabetes Mellitus (DM), hyperlipidemia and positive history for coronary artery disease were higher in MetS group, whereas, the ratio of smokers was higher in the control group. The incidence of in-hospital death and MACE was not statistically different in MetS and control groups. Presence of MetS was not correlated with in-hospital death and MACE in univariate analysis. In multivariate analysis using model adjusted for age, gender, DM/ fasting glucose >100 mg/dL, left ventricular ejection fraction, post-PCI TIMI flow grade <3 and high creatinine and peak CK-MB levels age, peak CK-MB and creatinine levels remained the independent predictors of in-hospital mortality. Peak CK-MB and creatinine levels were also independent predictors of in-hospital MACE. Conclusion: Presence of MetS was not a predictor of in-hospital adverse events in patients with STEMI treated with primary percutaneous intervention. Peak CK-MB and creatinine levels may indicate higher risk for in-hospital adverse events.