Alpay Turan Sezgin

Increased High Sensitive CRP Level and Its Significance in Pathogenesis of Slow Coronary Flow

Previous studies have suggested that microvascular abnormalities cause slow coronary flow (SCF). The role of inflammation has not been investigated, to date. The purpose of this study was to determine the role of inflammation in pathogenesis of SCF. The study included 32 patients with angiographically proven SCF (mean age 49 ±9 years) (group I) and 30 subjects with normal coronary flow (mean age 48 ±8 years) (group II). Blood samples were collected for high sensitive CRP (hs-CRP) measurements. Thrombolysis in myocardial infarction frame count (TFC) was compared in both groups. Distribution of sex, age, body mass index (BMI), arterial blood pressure, and ejection fraction were similar in the 2 groups. TFC was significantly higher in group I than in group II for each artery including left anterior descending coronary artery (LAD), left circumflex artery (Cx), and right coronary artery (RCA) (38.9 ±6.6 vs 22.1 ±1.8 frames, p = 0.0001; 39.6 ±4.9 vs 22.3 ±1.8 frames, p = 0.001 ; 39.0 ±3.8 vs 22.0 ±1.8 frames, p = 0.001, respectively). In group I, serum hs-CRP concentration was significantly higher than that of group II (0.6 ±0.58 vs 0.24 ±0.1 mg/dL p = 0.03). Correlation analysis showed a positive correlation between hs-CRP level and TFC for each artery (for CTFCLAD, r = 0.36 p = 0.004; for TFCCx, r = 0.42 p = 0.003; and for TFCRCA, r = 0.42, p = 0.0001 respectively). Increased hs-CRP level suggests that inflammation may be associated with pathogenesis of SCF or at least in part contributes to its pathogenesis. Increased hs-CRP level may also be an early marker of impaired coronary blood flow.

Different effects of atenolol and nebivolol on coronary flow reserve

Atenolol and nebivolol are commonly used antihypertensive agents. Nebivolol increases both stimulated and basal release of endothelial nitric oxide, thereby improving flow-mediated dilatation of the brachial artery in patients with essential hypertension.1 However, it is believed that atenolol has no effect on arterial vasoreactivity.1nnPharmacological stress transthoracic second harmonic Doppler echocardiography (TTDE) is a useful tool in evaluating coronary flow reserve (CFR). Several studies have evaluated its feasibility.2nnWe hypothesised that in patients with essential hypertension, nebivolol can reverse coronary microvascular dysfunction and improve CFR.nnAfter one month of lifestyle changes, 63 consecutive patients with hypertension had 24 h ambulatory blood pressure monitoring. Hypertension was diagnosed in 30 of these who had average daytime blood pressure > 135/85 mm Hg and average night-time blood pressure > 125/75 mm Hg. These 30 patients constituted the study population. For the control group, 30 healthy volunteers were enrolled. Patients with known cardiovascular risk factors, those who were taking any vasoactive or hypertension drug, and those with ECG changes specific for myocardial ischaemia were excluded from the study. Written informed consent was obtained from each participant, and the institutional ethics committee approved the …

Comparison of direct stenting versus conventional stent implantation on blood flow in patients with ST-segment elevation myocardial infarction

As compared with balloon angioplasty, stent implantation in treatment of acute myocardial infarction (AMI) reduces abrupt vessel closure, restenosis, and reocclusion rate. However, a few studies have demonstrated the safety and feasibility of direct stenting compared to conventional stent implantation technique. This study was designed to compare possible advantages of direct stenting with conventional stent implantation on immediate coronary blood flow and short-term clinical benefits in patients with AMI. Fifty patients with AMI who underwent mechanical revascularization were eligible for the study. The patients were randomly assigned to undergo either direct stenting (n=25) or conventional stent implantation (n=25). Before and after the procedure thrombolysis in myocardial infarction (TIMI) flow and postprocedural corrected TIMI frame count (cTFC) of the infarct-related artery were measured. There was no difference in TIMI flow distribution at baseline between the 2 groups. TIMI 3 flow rate significantly increased after procedure in both groups compared to baseline (p<0.05). Postprocedural cTFC was found significantly lower in the direct stent arm compared to conventional stenting (p<0.001). Both during and after the procedure the complication rate and procedural time were lower in the direct stenting arm. Direct stenting provides better immediate coronary blood flow and is a safe and feasible method compared with conventional stenting in patients with AMI. Improvement in coronary blood flow measured by the corrected TIMI frame count method may suggests a significant reduction of microvascular injury.

Effect of slow coronary flow on electrocardiographic parameters reflecting ventricular heterogeneity

QT interval dispersion reflects regional variations in ventricular repolarization and cardiac electrical instability. Previous studies have showed that QT interval dispersion changes during episodes of myocardial ischemia. Slow coronary flow (SCF) in epicardial coronary arteries is a rare and unique angiographic finding. Whether this pattern of flow is associated with electrocardiographic abnormalities is unknown. Therefore, this study was designed to investigate whether SCF results in electrocardiographic (ECG) changes compared to normal coronary flow. For this aim 24 patients with angiographically proven SCF who had no obstructive coronary lesion (group I) and 25 patients without coronary artery disease (group II) were included in the study. Both groups underwent a routine standard 12-lead surface electrocardiogram recorded at 50 mm/s during rest. QT dispersion (QTd), corrected QT (QTc), and corrected QT dispersion (QTcd) were calculated. Distributions of sex, age, body mass index (BMI), and cardiac risk factors were similar in the 2 groups. Mean heart rate was similar in the 2 groups (74 ±8 vs 77 ± 7 p > 0.05). Mean QRS interval durations were similar in the groups (92 ±7 vs 90 ±6 ms p > 0.005). In group I, QTd, QTcd, and QTc, were significantly higher than in group II (QTd: 73 ±14 vs 40 ±14; QTcd: 71 ±15 vs 42 ±9; QTc: 414 ±14 vs 388 ±13, respectively p <0.05). In conclusion, SCF was found to be associated with prolonged QT interval and increased QT dispersion. Ischemia in microvascular level and/or altered autonomic regulation of the heart may be responsible mechanisms.

An unusual cause of mismanagement in an acute myocardial infarction case: pseudothrombocytopenia

Thrombocytopenia determined by an automated counter may represent a benign, incidental finding in an asymptomatic patient or a potentially life-threatening disorder. Even if the low platelet count actually is a benign condition itself, in some conditions, any delay resulting from this condition consequently may be seriously hazardous. Low platelet count may alter the decision of heparin administration, which is an essential part of management during acute coronary syndromes. EDTA-dependent pseudothrombocytopenia (PTCP) is reported to have a prevalence of 0.1% in a general hospital; however, it is also reported that around 15% of the patients referred for a specialized center for isolated thrombocytopenia are actually cases of PTCP. In this report, we describe a patient with PTCP who could not receive reperfusion therapy during acute myocardial infarction because of the low platelet counts reported by an automated counter.

On-pump/beating-heart myocardial protection for isolated or combined coronary artery bypass grafting in patients with severe left ventricle dysfunction : assessment of myocardial function and clinical outcome

BACKGROUNDnMyocardial protection in coronary artery bypass grafting (CABG) with severe left ventricular (LV) dysfunction is still a surgical dilemma. Preoperative myocardial infarction (MI) and postoperative low output syndrome are serious complications in cases of inadequate protection of the heart, which has limited myocardial reserve. The aim of this study was to evaluate myocardial function and clinical outcome after on-pump/beating-heart CABG in patients with severe LV dysfunction.nnnMETHODSnBetween March 2001 and March 2004, clinical, operative, and postoperative data were prospectively collected from patients with LV ejection fraction (EF) < 30% who underwent on-pump/beating-heart CABG and associated procedures.nnnRESULTSnThere were 46 patients and the mean patient age was 58.38 +/- 9.23. The mean EF was 25.6 +/- 2.8%. Operating time was 275 +/- 63 minutes. The frequency of distal anastomosis was 3.06 +/- 1.04. Twenty-four patients required aneurysmectomy in addition to CABG, and 2 of the 24 required mitral repairs. Inotropic support was required in 14 patients (30%) and 5 of them (10.9%) also required IABP. The LV EF improved significantly after the operation when compared to preoperative measurements (25.6 +/- 2.8 versus 33.64 +/- 4.69, P < .05). Hospital mortality rate was 4.3% (2 of the 46 patients). No mortality was observed at a mean followup of 16 months after discharge from the hospital.nnnCONCLUSIONSnOn-pump/beating-heart CABG technique is effective in protecting myocardial functions in patients with severe LV dysfunction. The main advantage of the on-pump/beating-heart technique is the ability it provides one to perform complete revascularization, and intracavitary procedures with low morbidity and mortality even in impaired LV function.

Short- and long-term effect of simvastatin therapy on the heterogeneity of cardiac repolarization in diabetic patients

The interlead variability of QT interval in the 12-lead electrocardiogram, QT dispersion (QTd), has been shown to reflect dispersion of ventricular refractoriness and may provide a measure of arrhythmogenic potential in diabetic patients. QTd and heart rate corrected QTd (QTcd) were also proposed to be accurate predictors of cardiac death in patients with diabetes. In recent years, experimental and clinical evidence demonstrates that statins exert antiarrhythmic properties. Therefore, in the present study, we have examined whether simvastatin treatment has any effect on the QTd and QTcd in patients with diabetes mellitus. Sixty type 2 diabetic patients without known coronary artery disease and low-density lipoprotein cholesterol >100mg/dl and 30 age and sex-matched non-diabetic controls were included in a prospective study. Out of 60 diabetic patients, 30 were treated with simvastatin 40 mg/day for 1 year and the remaining 30 subjects were served as diabetic controls. No lipid lowering therapy was administered to the diabetic and the non-diabetic controls. QTd and QTcd of treated diabetics and the non-diabetic controls were measured at baseline, 6, 12 weeks and at 1 year. QTd and QTcd of the diabetic controls were obtained at baseline, 6 and 12 weeks. Both QTd and QTcd were significantly greater in patients with the diabetes than in the non-diabetic controls at baseline (52+/-13 ms vs. 41+/-12 ms, p<0.001 and 62+/-17 ms vs. 42+/-11 ms, p<0.001, respectively). Simvastatin therapy significantly decreased both QTd and QTcd at the end of first year compared to baseline (51+/-15 ms vs. 33+/-11 ms, p<0.001 and 60+/-18 ms vs. 38+/-12 ms, p<0.001, respectively). No significant change were found in QTd and QTcd in the non-diabetic (p=0.29 and p=0.87 by ANOVA, respectively) and in the diabetic controls (p=0.72 and p=0.57, by ANOVA, respectively). This study suggests for the first time that simvastatin treatment in diabetic patients with hyperlipidemia is associated with an improvement in the heterogeneity of cardiac repolarization. This may be one of the mechanisms for the reduction in clinical events reported in the survival studies with statins. Further prospective randomized studies are warranted to confirm our findings.

Teleconsultation of coronary angiograms using smartphones and an audio/video conferencing application

OBJECTIVEnTo examine the feasibility and accuracy of teleconsultation of coronary angiograms using iPhone 4 and FaceTime.nnnMETHODSnThe study was conducted in two stages. Coronary angiograms of 100 patients with single-vessel disease were retrospectively selected by a core laboratory unit and then re-evaluated by a consultant cardiologist on both an iPhone 4 screen via the FaceTime application and on the workstation monitor of the angiography laboratory. The interpretations of the consultant cardiologist on localization and severity of angiographic lesions were recorded and compared with those of the core laboratory. Using the same teleconsultation system, the consultant cardiologist outside the hospital was presented live angiographic images of 10 patients undergoing primary percutaneous coronary intervention (PCI) for acute myocardial infarction.nnnRESULTSnInterpretations of the consultant cardiologist on the localization and severity of 100 lesions on both the smartphone screen and workstation monitor showed high levels of agreement with the results of the core laboratory (for all, κ > 0.80). Of 10 patients whose PCI was performed under live video teleconsultation, eight patients underwent successful PCI while two patients had normal coronary arteries. There was an excellent agreement between the consultant cardiologist and the operator regarding lesion localization.nnnCONCLUSIONSnSmartphones allow highly accurate interpretations on angiographic lesions and thus may serve as a supplementary teleconsultation tool in both elective and emergency situations.

Contribution of Plasma Lipid Disturbances to Vascular Endothelial Function in Patients With Slow Coronary Flow

Previous studies have suggested that microcirculatory abnormalities cause slow coronary flow (SCF). However, the underlying mechanism of this phenomenon has not yet been well documented. Therefore, the aim of this study was to determine the role of plasma lipid disturbances in pathogenesis of slow coronary flow (SCF). Forty patients with SCF (group I) and 37 subjects with normal coronary arteries (group II) were included in the study. In each subject plasma lipid concentrations (total cholesterol [TC], low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C], and triglyceride [TG]) and brachial artery flow-mediated dilatation (FMD) and nitroglycerin (NTG)-induced dilatation were measured. Total cholesterol level was found to be similar in the 2 groups. In group I, HDL-C level was lower than in group II (34 ±3 vs 40 ±4 mg/dL, p=0.0001). In group I, TG level was higher than in group II (213 ±29 vs 198 ±24 mg/dL p=0.002). In group I, FMD was smaller than that of group II (3.48 ±3.1% vs 10.4 ±5.6%, p=0.0001). The percent NTG-induced dilatation was not different between the groups (15.5 ±5.3% vs 17.3 ±6.9%, p=0.27). On regression analysis; there was a significant relationship between percent of FMD and HDL-C (r =0.65, p=0.0001). When the 2 groups were analyzed separately, HDL-C was still related to percent of FMD in both groups (r =0.47 p=0.002 and r =0.45 p=0.005, respectively). Multivariate regression analysis showed that only plasma HDL-C was independently related to FMD (F=7.5 p=0.0001). In patients with SCF, reduced flow-mediated dilatation was detected and was found to be associated with plasma lipid disturbances, principally low HDL and high TG levels.

Increased thrombolysis in myocardial infarction (TIMI) frame count in patients with aortic stenosis but normal coronary arteries.

Aortic stenosis (AS) with otherwise normal coronary arteries may be associated with angina pectoris and microvascular abnormalities. In this study, using the thrombolysis in myocardial infarction (TIMI) frame count (TFC) method, we tested whether the coronary blood flow velocity is decreased in patients with AS. Twenty-eight patients with severe AS and an otherwise normal coronary arteriogram (group I) and 25 subjects with atypical chest pain and a normal coronary arteriogram (group II) were included in this study. After transthoracic echocardiographic evaluation, all participants underwent coronary arteriography either to evaluate their coronary artery status before surgery or to exclude coronary artery disease. Later, TFC was calculated and compared for each artery, including the left anterior descending (LAD), circumflex (Cx), and right coronary arteries (RCA) in both groups. Baseline characteristics of the study groups were similar. In both groups, TIMI-3 flow was present in each artery at the time of arteriography and the coronary arteries were entirely normal. All subjects with AS had echocardiographic septal and posterior wall thickness more than 12u2009mm. The mean aortic valve area was 0.78 ± 0.26u2009cm2. Peak and mean transvalvular gradients were 92 ± 16 and 48 ± 7, respectively. In group I, corrected TFC, Cx, and RCA frame counts were significantly higher than those of group II (24.6 ± 2.1 vs 21.8 ± 2.2 frames/s, P < 0.05; 24.4 ± 1.7 vs 22.8 ± 2.4 frames/s. P < 0.05; 23.2 ± 2.0 vs 21.4 ± 1.8 frames/s, P < 0.05, respectively). Coronary blood flow velocity is decreased in patients with aortic stenosis compared with patients having normal coronary arteries, probably due to microvascular dysfunction.