Cem Bostan

Long-Term Follow-Up of Patients at High Risk for Nephropathy After Contrast Exposure

Contrast medium-induced acute kidney injury (CI-AKI) is associated with morbidity and mortality, but the long-term outcomes of patients who do not develop CI-AKI remain unknown. We assessed clinical end points during long-term follow-up in patients at high risk for nephropathy who did not develop CI-AKI. Patients (n = 135) with impaired renal function (estimated glomerular filtration rate: 30-60 mL/min/1.73 m2) were divided into 2 groups according to contrast media (CM) exposure. The primary end point of this study was a composite outcome measure of death or renal failure requiring dialysis. Multivariate analyses identified CM exposure to be independently associated with major adverse long-term outcomes (hazard ratio: 2.3; 95% confidence interval, 1.34-6.52; P = .018). Even when CM exposure does not cause CI-AKI in patients with impaired renal function, in the long term, primary end points occur more frequently in patients exposed to CM than in those with no CM exposure.

The Relationship Between Chronic Kidney Disease and SYNTAX Score

Chronic kidney disease (CKD) is associated with increased risk of cardiovascular disease and death. We evaluated the association between CKD and severity of coronary artery stenosis by calculating SYNTAX Score in patients with left main coronary artery and/or 3-vessel coronary artery disease. Coronary angiograms of 217 patients were assessed. Chronic kidney disease was staged using the estimated glomerular filtration rate (eGFR, mL/min per 1.73 m2) prior to coronary angiography. Patients were divided into 5 groups according to the National Kidney Foundation Kidney Disease Outcome Quality Initiative (NKF KDOQI) Clinical Practice Guidelines (14). Patients with eGFR >90 mL/min per 1.73 m2 (group 1), patients with eGFR 60 to 89 mL/min per 1.73 m2 (group 2), patients with eGFR 30 to 59 mL/min per 1.73 m2 (group 3), patients with eGFR >15 to < 30 per 1.73 m2 and dialysis patients with eGFR < 15 per 1.73 m2 were combined as group 4. The risk of significant lesion complexity increased progressively with decreasing kidney function (P = .001). Estimated glomerular filtration rate was a strong predictor of higher SYNTAX Score.

Relationship Between Increased Serum Resistin Level and Severity of Coronary Artery Disease

Resistin, which is derived from the gene of RSTN, belongs to a family of cysteine-rich secretory proteins called resistin-like molecules (RELMs). Increased serum resistin levels are associated with coronary artery disease (CAD) and the risk of cardiovascular death. Patients (n = 214) with an initial diagnosis of stable angina pectoris, unstable angina pectoris, and myocardial infarction without ST-segment elevation and referred to catheter laboratory for coronary angiography were enrolled in the study. We aimed to investigate the relationship between increased serum resistin level and CAD. The severity of CAD was calculated by the Gensini scoring system. In conclusion, we established a significant correlation between serum resistin levels and CAD (P = .010). Also, serum resistin levels correlated with the Gensini score that represents the severity of CAD angiographically (P = .010).

Platelet-to-Lymphocyte Ratio Predicts Contrast-Induced Nephropathy in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome.

We assessed the relation between platelet-to-lymphocyte ratio (PLR) on admission and contrast-induced nephropathy (CIN) in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). A total of 488 patients with NSTE-ACS who underwent urgent coronary angiography were enrolled. Levels of PLR and creatinine were measured before angiography and at 72 hours after angiography. Patients were divided into 2 groups, namely, the CIN group, 80 patients (16.3%; age 65.3 ± 12.5years; 66.7% men) and the non-CIN group, 408 patients (83.7%; age 61.2 ± 12.3 years; 72.5% men). Patients in the CIN group had significantly higher PLR than those in the non-CIN group (152.9 ± 99.6 vs 120.4 ± 66.1, P < .001). In logistic regression analysis, PLR (odds ratio [OR] 1.004, 95% confidence interval [CI] 1.001-1.007, P = .02), diabetes mellitus (OR 1.75, 95% CI 1.02-2.98, P = .03), and ST-segment depression on admission electrocardiogram (OR 1.68, 95% CI 1.00-2.81, P = .04) were independent predictors of CIN. The PLR was an independent predictor of CIN after angiography in patients with NSTE-ACS.

Beneficial effects of rosuvastatin treatment in patients with metabolic syndrome.

We determined the effect of 6-month rosuvastatin treatment on blood lipids, oxidative parameters, apolipoproteins, high-sensitivity C-reactive protein, lipoprotein(a), homocysteine, and glycated hemoglobin (HbA1c) in patients with metabolic syndrome (MetS). Healthy individuals (men aged >40 years and postmenopausal women) with a body mass index ≥30 (n = 100) who fulfilled the National Cholesterol Education Program Adult Treatment Panel III diagnostic criteria for MetS were included. Total cholesterol and low-density lipoprotein cholesterol (LDL-C) levels decreased (P < .0001). The change in LDL 1 to 3 subgroups was significant (P = .0007, P < .0001, and P = .006, respectively). Changes in LDL 4 to 7 subgroups were not significant. There was a beneficial effect on oxidized LDL, fibrinogen, homocysteine, and HbA1c. Rosuvastatin significantly increased high-density lipoprotein levels (P = .0003). The oxidant/antioxidant status and subclinical inflammatory state were also beneficially changed. Rosuvastatin had a significant beneficial effect on atherogenic dyslipidemia as well as on oxidative stress and inflammatory biomarkers in patients with MetS.

Cardiac amyloidosis cases with relative apical sparing of longitudinal strain.

Amyloidosis is a clinical disorder caused by extracellular deposition of insoluble abnormal fibrils, derived from aggregation of misfolded normally soluble protein. Cardiac amyloidosis (CA) describes clinically significant involvement of the heart by amyloid deposition, which may or may not be associated with involvement of other organs. An echocardiogram demonstrating marked left ventricle (LV) wall thickening particularly in the absence of hypertension, biatrial enlargement, thickened valve leaflets, and a pericardial effusion in the context of reduced voltage of R-waves in electrocardiogram (ECG) is highly persuasive of cardiac amyloid. If either a thickened interatrial septum or a granular highly echogenic myocardium is also present, this makes the diagnosis even more likely. This thickening is often referred to incorrectly as “hypertrophy” because the pathological process is infiltration, not myocyte hypertrophy. The absence of high ECG voltages in advanced disease may be more specific for infiltrative diseases, of which amyloid is the most common. Echocardiography in CA can detect abnormalities in systolic and diastolic function of the myocardium even before ejection fraction (EF) is impaired. Strain (S) and strain rate (SR) has been shown to be superior to tissue Doppler techniques in this respect. Lately, the prognostic value of S and SR was, also, shown. We report 2 cases with similar clinical and echocardiographic features highly suggestive of CA. First patient (patient A) was a 50-year-old male. He had history of familial Mediterranean fever for several years using cholchicum dispert. The second patient (patient B) was also male (48year old). He had type 2 diabetes mellitus controlled with oral antidiabetic drugs. Both had no history of ischemic and hypertensive heart disease and had symptoms and signs of congestive heart failure. Their ECGs were similar presenting low voltage in limb leads. Patient A had also anterior and inferior pseudoinfarct pattern (Fig. 1A, B). Their transthoracic echocardiography (GE Healthcare, Horten, Norway) revealed increased wall thickness and systolic dysfunction in both LV and right ventricle (RV). (LV EF 30%, Tricuspid Annular Plane Systolic Excursion 1.3 cm) with normal chamber size, mild-to-moderate mitral and tricuspid insufficiency, mild pulmonary hypertension, and mild pericardial effusion. (Fig. 2A, B) We also performed twodimensional speckle tracking echocardiography (GE Healthcare). Longitudinal strain (LS) measurements were performed off line using automated software (EchoPAC Version 108.1.2. Advanced Analysis Technologies; GE Healthcare), using 3 standard apical views, the LV endocardium was manually identified and tissue speckles were automatically tracked frame by frame throughout the cardiac cycle. A bull’s-eye plot illustrating segmental LS values was automatically generated. Both the patients had lower global LS. ( 7.5, 4.5). The majority of segments in the basal and mid-ventricular regions had reduced LS, whereas apical segments had normal LS. Apical sparing was consistently seen in both (Fig. 3A, B). Patient A who had a salivary gland biopsy which showed non AA type amyloid deposition died 1 month after the diagnosis of congestive heart failure. Patient B had a rectal biopsy which showed AA type amyloid deposition and is still being followed. Amyloidosis should be considered in any patient older than 40 years who has nephrotic syndrome, congestive heart failure (not on an ischemic basis), idiopathic peripheral neuropathy, or unexplained hepatomegaly. There is an increasing realization that the prevalence of CA may be higher than previously expected and, not uncommonly, that the diagnosis can go unrecognized. Although a tissue biopsy is required to define the type of CA, the clinical challenge Address for correspondence and reprint requests: Cem Bostan, M.D., Department of Cardiology, Istanbul University, Institute of Cardiology, Haseki, Fatih 34350 Istanbul, Turkey. Fax: 90 (216) 469-3796; E-mail: bostancem@yahoo.com

Percutaneous coronary intervention vs. optimal medical therapy – the other side of the coin: medication adherence

Although many studies have examined medication adherence in patients with coronary artery disease (CAD), no prospective trial has compared medication adherence between patients treated with percutaneous coronary intervention (PCI) or with optimal medical therapy (OMT) in real life. This study sought to compare the adherence to evidence‐based secondary preventive medications in patients with documented CAD treated with PCI and OMT, or OMT alone.

Four-Dimensional Speckle Tracking Echocardiography in Patients with Hypertrophic Cardiomyopathy.

Abnormal left ventricular (LV) deformational mechanics have been demonstrated in patients with hypertrophic cardiomyopathy (HCM) using two‐dimensional (2D) speckle tracking echocardiography, but there is not enough information about the four‐dimensional speckle tracking echocardiography (4DSTE) in these patients. The objective of the study was to identify and quantify the left ventricular contractility in patients with HCM using 4DSTE.

Epicardial cysts: report of two rare cases.

Epicardial cysts originating directly from the epicardium are seen very rarely. Complete surgical excision is recommended when these cysts are detected. If cysts compress surrounding vital structures, cardiopulmonary bypass (CPB) should also be considered. We report herein 2 cases of multiloculated epicardial cysts, both of which were successfully excised, 1 with CPB.

Admission Hyperglycemia and TIMI Frame Count in Primary Percutaneous Coronary Intervention

We evaluated the relationship between admission blood glucose levels and estimated coronary flow by the thrombolysis in myocardial infarction (TIMI) frame count (TFC) method in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). The TFC of 121 consecutive patients with STEMI were evaluated after pPCI. Patients with admission glucose levels >198 mg/dL (11 mmol/L) were defined as hyperglycemic. Hyperglycemia was observed in 36 (29.8%) patients. The TFC was significantly higher in patients with hyperglycemia (70.75 [10-96] vs 56.87 [8-100], P = .04). No-reflow frequency was higher in the hyperglycemia group (44.4% vs 23.5%, P = .02). In multivariate linear regression analysis admission glucose was an independent predictor of high TFC (B = 0.21, P = .02). Our findings suggest that admission blood glucose is a predictor of TFC which reflects coronary blood flow.