Ertugrul Okuyan

Cardiac effects of “mad honey”: a case series

Background. Grayanotoxins (GTX), also known as andromedotoxins, are produced by plants of the Ericacae family. This toxin is responsible for “mad honey” intoxication, which can present with fatal cardiac bradyarrhythmias and circulatory collapse. GTXs lead to cardiac toxicity because they increase sodium channel permeability and activate the vagus nerve. Objective. We evaluated 42 patients (33 males) prospectively who had been hospitalized with diagnosis of “mad honey” intoxication in a state hospital setting. Methods and results. The median age of patients was 48.5 years and all patients were admitted with complaints of nausea, vomiting, dizziness, fainting, and sweating. Five of the patients had syncope before admission. On admission, the mean systolic blood pressure was 73.1 ± 12.7 mmHg, the mean diastolic blood pressure was 52.1 ± 11.3mmHg, mean heart rate was 38 ± 7 bpm. On initial electrocardiograms, 18 patients had sinus bradycardia, 15 patients had complete atrioventricular block, and 9 patients had nodal rhythm. All patients were monitored in a coronary care unit and treated sympomatically with atropine, intravenous fluids, and dopamine. None of the patients needed temporary pacing and all were discharged without complications. Conclusion. “Mad honey,” which is produced widely in northern parts of Turkey can be toxic. This intoxication should be considered in patients admitted to emergency department with bradycardia and hypotension especially in regions where this honey is produced.

Neutrophil to Lymphocyte Ratio is Related to Stent Thrombosis and High Mortality in Patients With Acute Myocardial Infarction

We investigated whether the neutrophil to lymphocyte ratio (NLR) can predict stent thrombosis (STh) and high mortality rate in patients with ST-segment elevation myocardial infarction (STEMI). We analyzed data of 102 patients with STh and 450 patients with STEMI admitted to 2 high volume hospitals. Preprocedural NLR was significantly higher in patients with STh (P < .001). There was a significantly higher mortality rate in patients with high NLR during hospitalization (P < .001). Also, in the STh group there was a significantly higher mortality rate in patients with high NLR (P < .001). In receiver–operating characteristic analysis, NLR >4.8 had 56% sensitivity and 68% specificity for predicting STh. The NLR >4.9 had 70% sensitivity and 65% specificity for predicting in-hospital mortality. On multivariate regression analysis, NLR was found to be significantly related to STh. In patients with STEMI, preprocedural high NLR is associated with both STh and higher mortality rates.

Platelet to lymphocyte ratio as a prognostic marker in primary percutaneous coronary intervention

Abstract We assessed the prognostic value of the platelet to lymphocyte ratio (PLR) in primary percutaneous coronary intervention (pPCI). Patients (n = 440) with acute myocardial infarction (AMI) who underwent pPCI were divided into 2 groups: low PLR (<137) and high PLR (>137). “Thrombolysis In Myocardial Infarction” (TIMI) flow grades and Syntax scores (SXS) were calculated from initial angiograms. In-hospital mortality rate and cardiac adverse events were obtained from medical records. Patients with high PLR had more no-reflow, higher SXS and higher mortality rate (p < 0.001, p < 0.001 and p = 0.008, respectively). In receiver operating characteristic curve analysis, high PLR predicted development of no-reflow (specificity 71% and sensitivity 85%), SXS>22 (specificity 52% and sensitivity 61%) and adverse events (specificity 67% and sensitivity 63%). In multivariate regression analysis, PLR was an independent risk factor for no-reflow, SXS>22 and in-hospital adverse events. In addition to PLR, we present the relationship between mean platelet volume, red cell distribution width and neutrophil to lymphocyte ratio and no-reflow, SXS and in-hospital adverse events.

Homocysteine levels in patients with heart failure with preserved ejection fraction.

Objectives: Increased homocysteine (HCY) levels are associated with an increased risk of cardiovascular disease. Plasma HCY is increased in chronic heart failure (CHF) patients, and previous studies suggest that hyperhomocysteinemia causes adverse cardiac remodeling and affects pump function. We aimed to evaluate the HCY levels in patients with diastolic heart failure with preserved left ventricular ejection fraction (LVEF). Methods: We prospectively studied 68 patients (39 females and 29 males) who were hospitalized for symptomatic heart failure, as well as 40 age- and sex-matched healthy subjects who comprised the control group. CHF was diagnosed in all cases based on Framingham diagnostic criteria. CHF with preserved LVEF was defined as cases with CHF with an LVEF of 50% or more. Patients with regional left ventricular wall motion abnormalities, atrial fibrillation, and renal failure were excluded. Results: The mean age was 65.5 ± 9.6 years in the heart failure group and 65.2 ± 9.7 years in the control group. The mean LVEF was 59.8 ± 5.3 in the heart failure group and 61.4 ± 5.2 in the control group. The mean total fasting HCY concentrations were significantly higher in patients with heart failure (16.9 ± 5.27 µmol/l vs. 10.15 ± 3.49 µmol/l, respectively; p < 0.001). Multiple regression analysis indicated that NT-proBNP, hs-CRP, E/A ratio, and HbA1C were independently associated with hyperhomocysteinemia. Conclusions: Our results suggest that hyperhomocysteinemia is prevalent in heart failure with preserved ejection fraction. Larger scale studies are needed to clarify its pathogenic mechanisms and effects on the natural history of heart failure.

Increased Transforming Growth Factor-β Levels Associated With Cardiac Adverse Events in Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is a common genetic heart disease characterized by ventricular hypertrophy, myocardial fibrosis, and impaired ventricular relaxation. The exact mechanisms by which fibrosis is caused remain unknown.

Lower vitamin D level is associated with poor coronary collateral circulation

Abstract Objectives. Vitamin D regulates calcium and bone homeostasis, and parathyroid hormone (PTH) secretion. Cross-sectional associations between lower vitamin D levels and cardiovascular diseases have been reported, but the relationship between vitamin D levels and collateral arteries in stable coronary artery disease (CAD) has not been reported before. Design. Two hundred and fourteen patients with above 95% stenosis in at least one epicardial coronary artery were consecutively recruited after coronary angiography (CAG) during the winter season. The coronary collateral circulation (CCC) was graded using Rentrop classification. Poor CCC group included patients with Rentrop Grade 0–1 CCC and control group included patients with Rentrop Grade 2–3 CCC. Vitamin D and PTH levels were measured on the day of CAG. Results. In the poor CCC group, vitamin D levels were lower (34 ± 25 pmol/L vs. 49 ± 33 pmol/L; p = 0.01) and the prevalence of vitamin D deficiency (< 37 pmol/L) was higher (67% vs. 43%; p = 0.01) compared to the controls. PTH levels, calcium, and phosphate levels were not significantly different between the groups. Female gender, lower HDL cholesterol, and lower vitamin D levels were independently correlated with poor CCC in the study population. Conclusion. Lower vitamin D levels may be associated with poor collateral development in patients with stable CAD.

Contribution of platelets indices in the development of contrast-induced nephropathy

Contrast-induced nephropathy (CIN) accounts for 10% of hospital-acquired renal failure, causes a prolonged in-hospital stay and represents a powerful predictor of poor clinical outcome. The underlying mechanism of the CIN development remains unclear and seems to be multifactorial. The potential link between platelet indices such as mean platelet volume (MPV) and platelet distribution width (PDW) with CIN is unknown. Herein, we aimed to investigate the correlation between MPV and PDW levels with the development of CIN. The incidence of CIN (20.5%) was prospectively evaluated in 430 patients with diagnosis of acute coronary syndrome. Initial creatinine (1.13 ± 0.25 vs. 1.05 ± 0.27 mg/dl, P = 0.01) and PDW (40.1 ± 20.2 vs. 34.5 ± 19.9%, P = 0.02) levels and the total volume of contrast media used (121 ± 61 vs. 94 ± 42 ml, P = 0.01) were higher in patients who developed CIN. MPV was similar between the two groups (P = 0.80). In a univariate regression analysis, age, increased creatinine, uric acid, phosphate, PDW levels and higher total volume of contrast media used were significantly correlated with CIN incidence. However, in a multivariate analysis, only total volume of CM used [odds ratio (OR) 1.011, 95% confidence interval (CI) 1.006–1.016; P = 0.01], increased age (OR 1.026, 95% CI 1.00–1.052; P = 0.05) and increased PDW levels (OR 1.009, 95% CI 1.00–1.022; P = 0.04) remained as the independent predictors of CIN. Among platelet indices, PDW, but not MPV, was associated with CIN development. The clinical significance of such link remains unclear, but may indicate involvement of platelet activation in CIN pathogenesis.

Higher copeptin levels are associated with worse outcome in patients with hypertrophic cardiomyopathy

Correlation of increased copeptin levels with various cardiovascular diseases has been described. The clinical use of copeptin levels in patients with hypertrophic cardiomyopathy (HCM) has not been investigated before.

Increased level of red cell distribution width is associated with poor coronary collateral circulation in patients with stable coronary artery disease.

OBJECTIVES Previous studies have shown the association between various hematological parameters and cardiovascular diseases, and their prognostic value. In this study, we compared red cell distribution width (RDW), neutrophil lymphocyte ratio (NLR) and mean platelet volume (MPV) measurements among patients with poor coronary collateral circulation (CCC) and well-developed CCC. STUDY DESIGN 326 patients with stable coronary artery disease (CAD) were evaluated retrospectively. CCC was graded by using the Rentrop classification. The poor CCC group included patients with Rentrop 0-1 CCC, and the good CCC group included Rentrop 2-3 CCC. RESULTS There were 171 subjects (84% male; mean age 56.6±10.4 years) in the poor CCC group, and 155 subjects (89% male; mean age 57.6±9.7 years) in the good CCC group. The total number of vessels with >95% stenosis (1.1±0.5 vs. 1.0±0.4; p=0.64) and Gensini scores (84.4±38.8 vs. 83.3±37.4; p=0.83) was not higher in the poor CCC group compared to the good CCC group. RDW was significantly higher in the poor CCC group compared to the good CCC group (14.19±1.36% vs. 13.89±1.19%; p=0.04). In multivariate logistic regression analysis, elevated levels of RDW and LDL were found to be independent predictors of poor CCC (OR 1.73, 95% CI: 1.30-2.29, p=0.01 and OR 1.01 95% CI 1.002-1.02; p=0.02, respectively). CONCLUSION In the present study, poor CCC was found to be independently correlated with RDW, but not with any other hematological parameters in patients with stable CAD.

Does SYNTAX score predict in-hospital outcomes in patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention?

BACKGROUND SYNTAX score (SxS) has been demonstrated to predict long-term outcomes in stable patients with coronary artery disease. But its prognostic value for patients with acute coronary syndrome remains unknown. AIM To evaluate whether SxS could predict in-hospital outcomes for patients admitted with ST elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (pPCI). METHODS The study included 538 patients with STEMI who underwent pPCI between January 2010 and December 2012. The patients were divided into two groups: low SxS (< 22) and high SxS (> 22). The SxS of all patients was calculated from aninitial angiogram and TIMI flow grade of infarct related artery was calculated after pPCI. Left ventricular systolic functions of the patients were evaluated with an echocardiogram in the following week. The rates of reinfarction and mortality during hospitalisation were obtained from the medical records of our hospital. RESULTS The high SxS group had more no-reflow (41% and 25.1%, p < 0.001, respectively), lower ejection fraction (38.2 ± 7.5% and 44.6 ± 8.8%, p < 0.001, respectively), and greater rates of re-infarction (9.5% and 7.3%, p = 0.037, respectively) and mortality (0.9% and 0.2%, p = 0.021, respectively) during hospitalisation compared to the low SxS group. On multivariate logistic regression analysis including clinical variables, SxS was an independent predictor of no-reflow (OR 1.081, 95% CI 1.032-1.133, p = 0.001). CONCLUSIONS SxS is a useful tool that can predict in-hospital outcomes of patients with STEMI undergoing pPCI.