Efe Edem

Does "smoker's paradox" exist in clopidogrel-treated Turkish patients with acute coronary syndrome.

Abstract Previously conducted studies revealed that smoking enhanced the efficacy of clopidogrel by increasing formation of the active metabolite (AM) from the prodrug through induction of the cytochrome CYP1A2. The expression of cytochrome enzymes depends on genotype and no data exists in literature conducted in Turkish patients comparing the clopidogrel responsiveness between active smokers and non-active smokers treated with clopidogrel. In this study, our aim was to investigate the clopidogrel responsiveness in clopidogrel-treated Turkish acute coronary syndrome (ACS) patients according to their smoking status. We retrospectively enrolled 258 patients who were hospitalized due to ACS. Clinical variables of the patients, especially smoking status were recorded. Clopidogrel resistance was evaluated by using adenosine diphosphate (ADP) induced platelet aggregometry. Clopidogrel resistance was detected as a change in maximal aggregation ≤20% from baseline. A total of 139 patients were active smokers while 12 were former smokers. 107 patients did not have a history of smoking. Ten of the smokers were hyporesponsive to clopidogrel, whereas 36 of non-smokers were hyporesponsive to clopidogrel (p < 0.001). Receiver-operating characteristic curve analysis demonstrated that Au-min value >612.5 predicted the clopidogrel resistance with a sensitivity of 60% (OR: 100.65, %95 CI = 19.996–506.615 p < 0.001). Results of this study demonstrated that ADP responses were lower in smokers receiving clopidogrel and aspirin than in non-smokers receiving the same drug regimen. This finding indicates that smoking was related to an enhanced clopidogrel responsiveness in Turkish patients hospitalized due to ACS, suggesting that “smoker’s paradox” probably exists in Turkish ACS patients.

An investigation of pulse transit time as a blood pressure measurement method in patients undergoing carotid artery stenting.

IntroductionPulse transit time (PTT) is the duration that a pulse wave takes to travel between two different arterial points, and it may be useful in estimating blood pressure. The aim of this study was to investigate the PTT during carotid artery stenting, as well as its value in blood pressure estimation. MethodThirty-four patients with critical carotid artery stenosis were enrolled in this study. The carotid PTT from the onset of the R-wave of electrocardiography to the pulse waveform at the carotid artery, obtained invasively during carotid artery catheterization, was measured. The carotid PTT was measured before and after stenting of the internal carotid artery. ResultsThe mean age was 70.4±8.0 years among the 34 patients enrolled (eight female patients, 21.9%). Measurements were obtained before and after carotid artery stenting. The heart rate (85.9±15.9 vs. 76.9±12.5 bpm, P<0.01), systolic blood pressure (162.8±28.6 vs. 126.0±31.7 mmHg, P<0.001), diastolic blood pressure (87.7±17.9 vs. 76.9±20.0 mmHg, P<0.01), and mean blood pressure (112.7±18.6 vs. 93.2±22.7 mmHg, P<0.001) were significantly decreased, whereas the carotid PTT (0.06±0.012 s vs. 0.07±0.012 s, P<0.001) was significantly increased after carotid stenting. The difference between the PTTs was negatively correlated with the systolic blood pressure (r=−0.35, P=0.02) and diastolic blood pressure (r=−0.4, P=0.01). ConclusionAfter carotid stenting, the PTT increases significantly because of the lowering of the blood pressure. However, the relationship is not strong enough for the PTT to be used for blood pressure estimation.

Acute Effusive Pericarditis due to Horse Chestnut Consumption

Patient: Male, 32 Final Diagnosis: Pericardial effusion related to the consumption of herbal product Symptoms: Dyspnea Medication: Horse chestnut (Aesculus hippocastanum L) Clinical Procedure: Pericardial and pleural effusions were drained through a pericardiopleural window Specialty: Cardiology Objective: Unusual clinical course Background: There are many well-known causes of pericardial effusion, such as cancer metastasis, bacterial or viral pericarditis, and uremic pericarditis; however, no reports exist in the literature demonstrating a pericardial effusion that led to cardiac tamponade following consumption of an herbal remedy. Case Report: A 32-year-old male patient was referred to our cardiology outpatient clinic with a complaint of dyspnea. The patient’s medical history was unremarkable; however, he had consumed 3 boxes of horse chestnut (Aesculus hippocastanum L) paste over the previous 1.5 months. His chest x-ray examination revealed an enlarged cardiac shadow and bilateral pleural effusion. On transthoracic echocardiographic examination, his ejection fraction was found to be 55% with circumferentially extended pericardial effusion that reached 3.9 cm at its maximal thickness. No growth had been detected in the pericardial and pleural biopsies or blood samples; there was no evidence of an infectious process in the physical examination. Based on this information, we diagnosed pericarditis resulting from the use of herbal remedies. This is the first report to demonstrate that herbal remedy consumption may cause this type of clinical condition. Conclusions: Besides other well-known causes, pericardial effusion related to the consumption of herbal remedies should always be considered when treating patients with pericardial effusion caused by unclear etiologies.

Renal subcapsular hematoma caused by hydrophilic guide wire during patent ductus arteriosus closure

Hydrophilic guide wire-associated renal subcapsular hematoma (RSH) during patent ductus arteriosus (PDA) closure is an extremely rare clinical condition. Herein, we present the case of a 16-year-old adolescent who suffered accidental hydrophilic 0.035-inch guide wire-related RSH during PDA closure. This RSH was diagnosed by computerized tomography and selective renal angiography. It was successfully treated by conservative treatment.

Acute myocardial infarction due to simultaneous occlusions of the left anterior descending artery and right coronary artery

Thrombosis of multiple coronary arteries at the same time is an uncommon angiographic finding during the course of ST-segment elevation myocardial infarction (STEMI). This clinical condition usually leads to cardiogenic shock or even sudden cardiac death. We present a case of a man who presented with STEMI due to simultaneous occlusions of the left anterior descending artery (LAD) and right coronary artery (RCA). A 57-year-old man was referred to our emergency department due to central chest pain and ST-segment elevations in anterior and inferior leads (figure 1). He did not have any particular diseases or well-described risk factors in his medical history. Based on ECG findings, his LAD was thought to …

Coronary compression by supposed cardiac hydatid cyst: an unusual cardiac mass

A 55-year-old female patient with a history of hepatic hydatid cyst presented with chronic stable angina. Echocardiography showed a cardiac mass. Her technetium-99m stress test was positive, so it was decided to perform coronary angiography (CAG). Coronary angiography performed on the next day revealed a chronic total occlusion of the proximal left anterior descending artery (LAD) with retrograde filling via collaterals from the right coronary artery (Figure 1 A). Cardiac magnetic resonance imaging (MRI) and multislice computed tomography (CT) angiography confirmed a myocardial hydatid cyst which involved the anterobasal wall of the left ventricle

Left ventricular twist was decreased in isolated left bundle branch block with preserved ejection fraction

Objective: Left ventricular (LV) rotation and twist play an important role in LV contraction and relaxation. Left bundle branch block (LBBB) deteriorates both diastolic and systolic functions. We evaluated the LV twist in patients with LBBB and preserved ejection fraction (EF) (>50%) to determine twist as a potential marker for subtle myocardial dysfunction. Methods: This observational cross-sectional study included 34 LBBB patients with preserved EF who were free from ischemic and valvular disease (Group 1) and 36 healthy controls (Group 2). All patients underwent 2-D Doppler and 2-D speckle tracking echocardiography. LV apical, basal rotation, and twist were evaluated in both groups and compared accordingly. In addition, subjects were dichotomized considering the median twist value of the study population. Binary logistic regression analysis was performed to determine the independent variables associated with inframedian twist. Results: Baseline clinical characteristics were similar in LBBB patients and controls. Mean apical rotation (2.5°±1.9° vs. 4.4°±2.9°; p=0.002), basal rotation (-2.9°±2.3° vs. -4.1°±2.7°; p=0.05), and twist (5.4°±3° vs. 8.6°±3.3°; p<0.001) were decreased in group 1. Parameters related to intra- and interventricular mechanical dyssynchrony, such as longitudinal left ventricular dyssynchrony index (LVdys) and preejection interval of LV, interventricular mechanical delay (IVMD), and left posterior wall contractions (SPMWD) were significantly higher in the LBBB group. The median twist value of the studied population was 6.65°. Binary logistic regression analysis showed that only presence of LBBB was independently associated with inframedian twist (OR=6.250; 95% CI: 2.215–17.632; p<0.001). Conclusion The LBBB might have induced the reduction of LV twist by diminishing the LV rotation before inducing a prominent effect on the left ventricular ejection fraction (LVEF). Therefore, twist may be considered as a marker for subtle LV dysfunction in LBBB with substantially normal EF.

Endovascular treatment of renal artery stenosis due to fibromuscular dysplasia - Is stent implantation underused in this circumstance?

Fibromuscular dysplasia (FMD) is a nonatherosclerotic and noninflammatory arterial disease that commonly affects the renal and carotid arteries. The primary target in treating patients with renal artery FMD is the control of blood pressure in order to prevent end-organ damage, which can be caused by poorly controlled hypertension. Invasive endovascular treatment should be taken into consideration both when hypertension cannot be controlled with medication. According to current opinion, hypertension attributed to renal artery FMD is often successfully treated solely with percutaneous renal balloon angioplasty (PRBA), with no requirement for stent implantation under most circumstances. However, an FMD recurrence after PRBA occurs frequently in these patients.

Well-described concertina effect during coronary angioplasty

A 59-year-old man was referred to our emergency department with a central chest pain at rest that radiated to both arms. He had a history of stent implantation in his right coronary artery (RCA) and his ECG showed signs of previous inferior myocardial infarction. His physical examination was normal and blood pressure was 130/80 mm Hg. Serial measured cardiac enzymes were not elevated, thus the patient was diagnosed with unstable angina pectoris. On the next day, coronary angiography revealed 40% stenosis in the mid-portion of the left anterior descending artery and 40% stenosis in the mid-portion of the circumflex artery. The stent in the mid-portion of his RCA was patent, however, the RCA was markedly tortuous with proximal minor irregularities followed by a …

A novel treatment approach for common carotid artery bifurcation aneurysms

An aneurysm involved in common carotid artery (CCA) bifurcation is a rare clinical condition. There are not enough natural follow-up data, and there is no evidence-based treatment algorithm [1]. An endovascular approach is used to treat CCA bifurcation aneurysms, as it offers some advantages in selected patient populations; nonetheless, closure of the aneurysmal segment in CCA bifurcation using a graft stent has some challenges, mainly occluding the ostial part of the external carotid artery (ECA). Coil embolization of a CCA bifurcation aneurysm is preferred over graft stent implantation in this condition; however, coil embolization cannot provide appropriate treatment in patients suffering from a CCA bifurcation aneurysm with significant stenosis in the proximal part of the internal carotid artery (ICA). Herein, we present a male patient whose CCA bifurcation aneurysm with significant stenosis in the proximal part of the ipsilateral ICA was successfully treated with the implantation of two nested self-expandable closed-cell stents.