Cagatay Ertan

Association of ST elevation with apical aneurysm in hypertrophic cardiomyopathy

OBJECTIVES Apical aneurysms in patients with hypertrophic cardiomyopathy (HCM) represent an underrecognized but clinically important subset of HCM patients. However it may be frequently missed by echocardiography because of poor image quality of left ventricular apex. We aimed to compare electrocardiographic STE in HCM patients with and without apical aneurysm. METHODS We developed this clinical review using an extensive MEDLINE review of the literature and data from our laboratories; and some electrocardiographic parameters including STE were analysed in HCM patients with and without apical aneurysm. RESULTS There were 29 HCM patients without apical aneurysm (Group 1; 52.6±17.7years, 69% male) and 28 HCM patients with apical aneurysm (Group 2; 59.6±13.2years, 57% male). The STE in V4-6 derivations were statistically more frequent in patients with apical aneurysm compared to those without aneurysm (93% vs 7%, p<0.001). There was a positive correlation between the presence of the STE in V4-6 derivations and the presence of the apical aneurysm (Spearmans ρ=0.895, p<0.001). CONCLUSIONS Clinicians and specifically echocardiographers must pay special attention on the electrocardiography to correctly detect the frequently overlooked apical aneurysm in HCM patients, and should be careful for apical aneurysm particularly in the presence of STE in V4-6 derivations.

Value of peri-procedural B-type natriuretic peptide levels in predicting cardiac events after elective percutaneous coronary intervention.

Objective — B-type natriuretic peptide (BNP) has diagnostic and prognostic value in a wide variety of cardiac disorders including heart failure and acute coronary syndromes.We aimed to evaluate the prognostic value of baseline and post-procedural BNP levels in predicting major adverse cardiac events (MACE) in stable coronary artery disease (CAD) patients undergoing elective percutaneous coronary intervention (PCI). Methods — Blood samples for BNP were obtained before, 1 hour and 24 hours after PCI of stable CAD patients who underwent elective PCI for de novo lesions in native coronary arteries. Patients were followed for 12 months for the occurrence of major adverse cardiac events (MACE) including cardiac death, myocardial infarction, hospitalization with angina or repeat revascularization. Results — Among the 95 patients with one-year follow-up data 22 had MACE. Baseline clinical and procedural characteristics of patients with and without MACE were similar. Only EF was significantly lower (P < 0.001) and complex lesion type was significantly more common in patients with MACE (P = 0.012). All measured plasma BNP levels were significantly higher in patients with MACE compared to those free of MACE (baseline P < 0.001, 1st hour P = 0.001 and 24th hour P < 0.001). Multiple logistic regression analysis identified the EF (P = 0.026) and 24th hour BNP (P = 0.002) as independent predictors of MACE. If baseline or post-PCI 1st hour BNP levels were put into analysis instead of post-PCI 24th hour BNP the predictive value of BNP lost its significance (both P > 0.05). Conclusion — Post-PCI 24th hour BNP is an independent predictor of MACE during 12 months of follow-up after elective successful PCI.

The Clinical Significance of Aspirin Resistance in Patients With Chest Pain

There are conflicting data in the literature about the clinical significance of aspirin resistance.

Is there any relationship between coronary artery disease and postprandial triglyceride levels

OBJECTIVE We aimed to evaluate the relationship between postprandial triglyceride (PPTG) levels and coronary artery disease (CAD). METHODS A total of 80 patients were included in this prospective cohort study. Oral lipid loading was used in order to measure PPTG levels. In the fasting state and after the high fat breakfast, triglyceride levels were measured by enzymatic methods at 2nd, 4th, 6th and 8th hours. We made subgroup analysis to show the effects of lipid loading on triglyceride levels in patients with and without fasting hypertriglyceridemia. We evaluated triglyceride levels and changes of triglyceride levels in percentages after lipid loading using a general linear model for repeated measures. Sample size analysis was performed. RESULTS Baseline clinical, demographic and laboratory characteristics of both groups were similar. The peak triglyceride levels were seen at the 4th hour in both groups. Triglyceride levels were significantly increased after lipid-rich-breakfast loading compared to baseline levels in both groups (p<0.001) but these changes were not significant (p=0.279). In patients with elevated fasting triglyceride levels, the area under the plasma triglyceride concentration curve was significantly larger in CAD group than control group (334±103 vs. 233±58 mg/dl, p=0.02). CONCLUSION Our data show that in patients who have a high fasting triglyceride level, high levels of PPTG may be related to CAD, however high PPTG levels are not related to CAD in patients with normal fasting levels of triglyceride.

Assessment of biochemical aspirin resistance at rest and immediately after exercise testing

Some aspirin-treated patients experience thromboembolic events, a phenomenon termed ‘aspirin resistance’, which may be clinical or biochemical by definition. Physical exercise is known to enhance platelet secretion and aggregability. To evaluate the presence of biochemical aspirin resistance at rest and immediately after exercise in individuals with stable coronary artery disease or coronary artery disease risk factors. We prospectively enrolled 101 patients who had received 100 or 300 mg/day enteric-coated aspirin for at least 7 days. Biochemical aspirin resistance (defined as normal collagen-epinephrine closure time < 165 s) was studied using the standardized platelet function analyzer. Of the 101 patients, 63 were aspirin sensitive both at rest and immediately after exercise, 18 exhibited biochemical aspirin resistance both at rest and after exercise, and 20 were aspirin sensitive at rest but exhibited biochemical aspirin resistance immediately after exercise. The results of exercise testing were similar in all three groups (each P > 0.05). Our results indicate that in almost 20% of the patients, aspirin did not seem to protect against exercise-induced platelet activation, despite the presence of aspirin sensitivity at rest. We did not, however, determine the extent to which the biochemical aspirin resistance noted in our study applied to clinical events.

Intramyocardial hematoma with epicardial rupture following percutaneous coronary intervention

Intramyocardial (or subepicardial) hematomas are uncommon conditions that occur mostly after myocardial infarction, percutaneous coronary intervention (PCI), coronary artery bypass surgery, cardiac surgery, or chest trauma. Coronary perforation is a rare complication of PCI and the subset of patients developing an intramyocardial hematoma, usually considered a catastrophic event, is even rarer. We describe here the case of 63‐year‐old man in whom an intramyocardial hematoma with epicardial rupture occurred after PCI. The patient was treated conservatively with a successful outcome.

Inappropriate shock and battery switching to “End of Life” in a patient with biventricular ICD during magnetic resonance imaging

Presence of a cardiac pacemaker or implantable cardioverter defibrillator (ICD) is a relative contraindication to magnetic resonance imaging (MRI). Biventricular ICDs are often used in the treatment of advanced heart failure; however, reports on experience with biventricular ICDs are lacking in the literature. In this case report, we describe a pacemaker-dependent patient with a biventricular ICD on whom an MRI of the lumbar spine was performed without having realized the presence of the ICD.

C-reactive protein levels increase after exercise testing in patients with increased platelet reactivity.

Aspirin has the potential to influence C-reactive protein (CRP) levels, an inflammatory marker, by its anti-inflammatory activity. Persistently increased platelet reactivity, however, can be detected with different laboratory methods despite aspirin therapy in some patients. The aim of this study was to investigate the effects of increased platelet reactivity on CRP levels at rest and after exercise in patients with documented or suspected coronary artery disease. Blood samples were collected from 100 patients (age, 58.1±8.5 years; 63.0% men) who were treated with 100 or 300 mg/day enteric-coated aspirin for at least 7 days, before and immediately after treadmill test for CRP analyses. Platelet reactivity was measured by the standardized platelet function analyzer-100, and increased platelet reactivity was defined as a normal collagen/epinephrine closure time (<165 s). Of the 100 patients, 82 had normal platelet reactivity (group A) and 18 had increased platelet reactivity (group B). The CRP levels increase was statistically significant after exercise in patients with increased platelet reactivity [group A: 2.3 (1.4–4.3) to 2.8 (1.6–4.9) mg/l, P=0.09; group B: 3.3 (2.0–4.5) to 4.7 (2.9–8.5) mg/l, P=0.02]. Detecting increased platelet reactivity is associated with an increase in CRP levels. The clinical significance of this finding needs to be further investigated.

Paracardiac Gossypiboma (Textiloma) in 2 Patients

Gossypiboma, also called textiloma, results when a cotton matrix such as a gauze pad or surgical sponge is left in a body cavity after surgery. The diagnosis of gossypiboma can be challenging. In symptomatic patients, operative removal of the pad or sponge is recommended; however, the decision to operate might be less immediately clear in asymptomatic patients. We report the cases of 2 patients in whom we diagnosed paracardiac gossypiboma. In addition, we briefly review other cases and discuss the treatment of asymptomatic patients.

Exercise-related QT interval shortening with a peaked T wave in a boy with MEN 2 syndrome

Multiple endocrine neoplasia 2 (MEN 2) is a hereditary syndrome associated with medullary thyroid carcinoma, pheochromocytoma (PCC), and hyperparathyroidism. PCCs in patients with MEN 2 are usually found in the adrenals after the manifestation of medullary thyroid cancer and are commonly bilateral and hormonally active. Unfortunately, a diagnosis of MEN 2 or PCC often is delayed until after the patient has developed an advanced MEN 2-related tumor. We present unusual electrocardiographic changes on exercise testing in MEN 2 syndrome. Transient peaked T waves and shortening QT during exercise stress testing may provide an early clue for undiagnosed PCC. <Learning objective: Stress testing is not just for the diagnosis of ischemia but it may be used to evaluate patients with symptoms that suggest exercise-induced arrhythmias. The pheochromacytoma is a disorder characterized by excess of catecholamines and is usually difficult to diagnose. Excessive sympathetic stimulation is toxic to myocytes and this toxicity may reveal itself as ECG changes such as peaked T waves and shortening of QT interval. Such changes on ECG during sympathetic stimulation such as exercise testing should raise the suspicion of pheochromacytoma.>.