Alp Burak Catakoglu

The relation between coronary flow rate, plasma endothelin-1 concentrations, and clinical characteristics in patients with normal coronary arteries.

BACKGROUND Coronary slow flow (CSF) is characterized by delayed opacification of epicardial arteries in the absence of occlusive disease. In the present study, we aimed to investigate the relation between coronary flow rate, plasma endothelin-1 (ET-1) concentrations, and clinical characteristics in patients with normal coronary arteries. METHODS The study population included 77 patients with angiographically normal coronary arteries who underwent coronary angiography on suspicion of ischemic heart disease due to typical chest pain or ischemic findings on treadmill exercise test or myocardial scintigraphy. Based on the Thrombolysis In Myocardial Infarction frame count (TFC), patients were grouped into those with normal coronary flow and those with slow coronary flow. RESULTS Forty-eight (61.5%) patients were found to have CSF. Plasma ET-1 concentrations were significantly higher with the presence of CSF (P=.03). There were significant differences between plasma ET-1 concentrations, and mean TFC, TFC for left anterior descending coronary artery (LAD), TFC for left circumflex coronary artery (CX), and TFC for right coronary artery separately in patients with and without CSF (P=.033, P<.001, P<.001, P<.001, and P<.001, respectively). Mean TFC, TFC for LAD, and TFC for CX, and ET-1 concentrations were significantly higher in smokers than in nonsmokers (P<.001, P<.001, P=.004, and P=.033, respectively). However, logistic regression analysis suggested that ET-1 concentration was not an independent determinant of CSF. CONCLUSIONS Although there is a significant relation between ET-1 concentrations and coronary flow rate, ET-1 concentrations are not sufficient to determine the presence of CSF. Smoking is strongly associated with CSF, TFC, and increased ET-1 concentrations.

Comparison of intracoronary versus intravenous administration of tirofiban in primary percutaneous coronary intervention

OBJECTIVE The purpose of this study was to compare the intravenous bolus dose of tirofiban with intracoronary bolus dose in primary percutaneous coronary intervention (PCI) with regard to in hospital and six months clinical outcomes and peak cardiac enzyme levels. METHODS We retrospectively examined 84 ST elevation myocardial infarction (STEMI) patients who underwent primary PCI from March 2006 to February 2007. All patients received the systemic bolus dose of tirofiban 10 mcg/kg either via intracoronary (IC) or intravenous (IV) route, followed by a 36 hours of IV infusion at 0.15 mcg/kg/min. Thirty six patients in IC group were compared with 48 patients in IV group in terms of peak cardiac enzyme levels, in-hospital and six months major adverse cardiac events (MACE) rates (death, myocardial infarction and repeat revascularization). Fishers exact test, Yates Chi-square, unpaired Students t-test and Mann-Whitney U test were used for statistical analysis. RESULTS There was no difference in cardiovascular risk profile or cardiac history between two groups. At six months the incidence of MACE was 6.25% in IV group and 11.1% in IC group (p=0.45). Peak cardiac phosphokinase (CPK) levels between IV and IC groups were also statistically non significant (2657+/-2181 U/L in IV group and 2529+/-1929 U/L in IC group) (p=0.92). CONCLUSION Intracoronary bolus application of tirofiban was not associated with reduction in MACE rates compared to intravenous administration in patients with STEMI who underwent primary PCI. Future prospective trials with higher bolus doses of IC tirofiban should addressed to clarify this issue.

Impact of anemia on nonfatal coronary events after percutaneous coronary interventions

Anemia is associated with higher rates of cardiovascular events in patients with heart failure, acute myocardial infarction, and in patients undergoing coronary artery bypass graft surgery. Although studies have focused on fatal coronary events in anemic patients following percutaneous coronary intervention (PCI), data is lacking regarding nonfatal coronary events. The aim of our study was to analyze the incidence of anemia in patients who developed nonfatal events after successful PCI, and to make a comparison with event-free patients. Forty-nine consecutive patients with and 51 without nonfatal coronary events (nonfatal myocardial infarction, coronary artery bypass grafting, or repeat PCI) during the 1-year follow-up after the index PCI procedure were included in the study. Anemia was defined using World Health Organization (WHO) criteria as a hematocrit value at initial presentation <39% for men and <36% for women. Baseline hematocrit levels were measured before the procedure. Baseline clinical, lesion, and procedural characteristics were comparable in both groups. Anemia was present in 33.8% of men and 30.4% of women. The incidence of anemia in patients with nonfatal coronary events was 46.9% and 15.7% in the event-free group, which was significantly different (P = 0.001). Anemia was found to be an independent risk factor for nonfatal coronary events in PCI patients (odds ratio: 2.24, 95% confidence interval: 1.05–4.79; P = 0.036). In conclusion, anemia is an important risk factor for predicting nonfatal coronary events after PCI. Although previous studies have shown its impact on fatal events, this study has demonstrated that anemia also has a role in nonfatal thrombotic coronary events and restenosis.

How to estimate left ventricular hypertrophy in hypertensive patients.

Left ventricular hypertrophy (LVH) is a structural remodeling of the heart developing as a response to volume and/or pressure overload. Previous studies have shown that hypertension is not an independent factor in the development of LVH and occurrence does not depend on the length and severity of hypertension, but the role played by other comorbidities such as triglycerides, age, gender, genetics, insulin resistance, obesity, physical inactivity, increased salt intake and chronic stress. LVH develops through three phases: adaptive, compensatory, and pathological phase. Contractile dysfunction is reversible in the first two phases and irreversible in the third. According to the Framingham study, LVH develops in 15-20% of patients with mild arterial hypertension, and in 50% of patients with severe hypertension. The pathophysiology of LVH includes hypertrophy of cardiomyocytes, interstitial and perivascular fibrosis, coronary microangiopathy and macroangiopathy. Individuals with LVH have 2-4 times higher risk of having adverse CV events compared to patients without LVH.

Response to the Letter to the Editor: "The correct number of double right coronary artery reported in the literature".

We would like to respond to the letter written by Sari et al regarding the correct number of published double right coronary artery (RCA) cases [1]. Our case [2] was presented as the second case who had an RCA with separate orifices according to the letter reported by Harikrishnan et al. in 2001 [3]. The case report entitled “Supernumerary right coronary artery” by Gupta et al was published in 1987 and was cited only by Lemburg et al. in 2007 [4] which was unavailable to us at the moment we have submitted the letter. Unfortunately, we could not see any citation of this article by Gupta et al in any of the previously reported cases about double RCA till October 2006, including the letter by Sari et al. published in 2006 [5]. The 3 cases reported by Kunimasa et al. and Lemburg et al. were published in 2007 [4,6] which were also not available for us to cite, since we have submitted our letter in October 2006. Also we observe conflict of data in the table summarizing the cases by year of publication by Sari et al. [5]. The cases presented by Lemburg and Kunimasa were shown to be published in 2006, whereas the articles were published in 2007 [4,6]. In addition, our case had been submitted in October 2006, whereas it was indexed in the table as 2007 by Sari et al. Although online publications serve for faster spread of knowledge it could not always be possible for the readers to review after full publication. The possibility of cases reported in journals not available to be reviewed globally could also change the real number of published cases of double RCA. We agree with the statement about importance of comprehensive literature search. Another crucial issue is to be objective and unbiased, without any conflicts in presented data. In conclusion double RCA is a rare coronary abnormality and awareness is recommended during coronary angiography.

The Highway Technique: a new stenting technique to treat coronary bifurcation lesions

AIMS We report a new stenting technique which was employed in 12 patients to treat coronary bifurcation lesions. METHODS AND RESULTS A stent is positioned in the main vessel together with a balloon in the side branch, which is positioned slightly proximal to the main vessel stent that also has enough length to cover the side branch ostium. Both the stent in the main vessel and the balloon in the side branch are inflated simultaneously. Following deflation, a double lumen is created in the main vessel, proximal to the bifurcation. The stent balloon is removed with the side branch balloon left deflated in its initial position. The main vessel is rewired with a third guidewire. The side branch balloon and guidewire are removed. The initial guidewire in the main vessel is directed to the side branch. A balloon is advanced and inflated in the side branch to dilate the struts of the main vessel stent that will provide the side branch entrance. The side branch balloon is left in place. A size matched balloon is advanced on the third guidewire that was advanced in the main vessel and inflated inside the stent with high pressure. Finally, kissing balloon inflation is performed at the bifurcation. Provisional stenting of the side branch can be performed when necessary. Final kissing balloon inflation is recommended after stenting of the side branch. CONCLUSIONS As a new coronary bifurcation stenting method, the Highway Technique has some advantages in side branch protection, with favourable immediate and 30-day clinical outcomes.

Relationship between endothelial dysfunction and cardiovascular risk factors and the extent and severity of coronary artery disease.

OBJECTIVES Endothelial dysfunction (ED) is associated with coronary artery disease (CAD) and cardiovascular risk factors. The relationship between cardiovascular risk factors, ED and the presence, extent and severity of CAD, was evaluated in patients with and without angiographically defined CAD in our study. STUDY DESIGN Eighty patients with CAD and 20 subjects with normal coronary arteries were included. Endothelial function was evaluated by endothelium-dependent, flow-mediated dilatation (FMD) and nitroglycerine-mediated dilatation (NMD) measurements, using brachial artery Doppler ultrasonography (USG). Cardiovascular risk factors were identified. The extent and severity of CAD was determined via vessel and modified Gensini scores. RESULTS FMD% and NMD% were significantly decreased in the CAD(+) group compared with the CAD(-) group (p=0.0001). In the CAD(+) group, the cut-off values of FMD% and NMD% in distinguishing between single-vessel and multi-vessel diseases were 8.5% (sensitivity: 95%, specificity: 62%) and 13.6% (sensitivity: 91%, specificity: 62%), respectively. Additionally, a modified Gensini score was significantly correlated with both FMD and NMD (r=-0.825, r=-0.778, respectively; p=0.0001) in the CAD(+) group. CONCLUSION ED was more prevalent in the CAD(+) group, and the degree of ED correlated well with the extent and severity of CAD.

Transcatheter aortic valve implantation: a novel perspective by real-time three-dimensional transesophageal echocardiography.

Behçet`s disease (BD) is a systemic inflammatory disorder with a wide variety of cardiovascular complications. Herein, we present a patient with BD and concomitant cerebral and coronary artery aneurysms. A 34-years-old man suffered from sudden severe headache followed by unilateral weakness of right extremities. Cerebral magnetic resonance angiography and conventional angiogram demonstrated a small aneurysm on M1 segment of the left middle cerebral artery which was successfully embolized (Fig. 1). Detailed history revealed recurrent oral and genital ulcerations and erythema nodosum. Leucocytosis, elevated serum C reactive protein levels, and positive HLA-B51 were also noted, and the patient was diagnosed with BD. During follow-up, he was consulted to cardiology due to dyspnea on exertion. Echocardiography revealed mild septal hypokinesia with a left ventricular ejection fraction (LVEF) of 45%. Coronary angiography revealed a small aneurysm originating from proximal left anterior descending artery (Fig. 2, Video 1-2. See corresponding video/movie images at www.anakarder.com). After intravenous pulse and oral methylprednisolone, interferon-α (9 million unit/3 times/week) and pulse cyclophosphamide treatment his symptoms diminished gradually and LVEF improved to 55% on control echocardiography that was performed 3 months later.

THE INTERACTION BETWEEN ENDOTHELIN-1 AND C-REACTIVE PROTEIN AND THEIR IMPACT ON LONG-TERM PROGNOSIS AFTER PERCUTANEOUS CORONARY INTERVENTION

Introduction: Previous studies have demonstrated unfavourable outcomes in coronary artery disease and percutaneous coronary intervention (PCI) patients with high endothelin-1 (ET-1) or high sensitivity C-reactive protein (hs-CRP) levels. The aim of our study was to investigate the impact of pre-procedural ET-1 and hs-CRP levels on major adverse coronary events (MACE) after PCI and to analyse a possible correlation between ET-1 and hs-CRP in this study population. Material and methods: Eighty consecutive PCI patients with a single de novo, non-occlusive coronary lesion were included. Blood samples were obtained immediately before the procedure. The study endpoint was the occurrence of MACE, which was defined as death (all causes), non-fatal myocardial infarction or repeat coronary revascularization (PCI or surgery). Results: At the end of the 24 months’ follow-up, 28 patients (35%) reached an end-point. We could not observe any correlation between ET-1 and hs-CRP in the overall patient group (r = 0.141, p = 0.213). Neither ET-1 nor hs-CRP levels were found to be predictive for MACE after PCI in multivariate analyses (p = 0.605 and 0.757 respectively). Conclusions: We could not demonstrate a relationship between pre-procedural ET-1 or hs-CRP levels and MACE at 24 months after successful PCI with single stent implantation to single de novo lesions. This study also could not show any correlation between ET-1 and hs-CRP levels in PCI patients.

Common Variants in the ATP-binding Cassette Transporter 1 Gene with Decreased HDL-Cholesterol Levels and Coronary Artery Disease

BACKGROUND Our aim was to determine whether the common variants within the coding sequence of ABCA1 gene affects low plasma high-density lipoprotein cholesterol (HDL-C) levels in Turkish patients with coronary artery disease (CAD). The study group was composed of 552 CAD patients, of which 251 had HDL-C levels < or =40 mg/dL, and 301 had HDL-C levels >40 mg/dL. METHODS PCR-RFLP was used to determine the A2589G and G3456C DNA polymorphisms of the ABCA1 gene. The study group was analyzed for potential clinical predictors of low HDL-C. RESULTS The GG variant of the ABCA1 gene A2589G polymorphism was found in 3.6% patients within the HDL-C < or =40 mg/dL group and in 4% of HDL-C levels >40 mg/dL group. Frequency distributions of the A2589G genotypes were not found to differ significantly among groups. The CC genotype of the G3456C polymorphism was found in 6.8% of HDL-C < or =40 mg/dL group and in 11.6% individuals of the HDL-C levels >40 mg/dL group. Frequency distributions of the G3456G genotypes were not significantly different among groups. The A2589G genotypes were not found to be effective over the analyzed lipid parameters. Among G3456C genotypes, in CAD patients with HDL-C < or =40 mg/dL the low-density lipoprotein (LDL-C) levels were elevated, whereas HDL-C levels decreased in CC genotype carriers compared to GG and GC. CONCLUSIONS No significant association was found between cardiovascular endpoints and ABCA1 gene A2589G and G3456C genotypes in this study population.