Fatih Şen

Left main coronary artery thrombosis and acute anterior myocardial infarction related to energy drink

A 32 year-old previously healthy man presented theemergency de-partment with a 6-hour history of retrosternal chest pain, palpitationsandemesis.Hissymptomsstarted5or6hafterdrinking5bottlesofen-ergy drink. He denied cigarettes, alcohol, cocaine or other drug uses.There was no family history of premature coronary artery disease.At admission his vital signs were blood pressure 178/92 mm Hg,pulse 85, temperature 37 °C, 98% oxygen saturation, and breathingwasrate22respirationsperminute.Physicalexaminationwasunremark-able.TheECGshowedmarkedSTelevationV2throughV6( Fig.1).Abed-side echocardiogram demonstrated anterior, apical and interventricularseptum hypokineses, and normal aorta and left ventricular EF was 35%.An emergent coronary angiogram performed demonstrated a largethrombus occupying nearly 90% of the diameter of the left main coro-nary artery and a second thrombus that occluded the proximal leftanterior descending artery (Fig. 2a,b,c). No atherosclerotic lesions orcoronary malformations were identified.After coronary angiogram we performed balloon angioplasty to a100% thrombotic LAD lesion.Before angioplasty intracoronary tirofibanbolus was administrated. After balloon angioplasty LADflow wasachieved at proximal segment but TIMI 0 flow at distal segment. Al-though repeated balloon angioplasty distal LADflow could not beachieved. After angioplasty procedure the patient was admitted to coro-narycareunit.After24-hourtiro fibanandheparininfusioncontrolangi-ography was planned but the patient refused control angiography.Further laboratory tests, including a lipid pro file and coagulation panel,were within normal limits. Anticardiolipin antibodies, homocysteinelevel, andprotein C and protein S activities were negative or within nor-mal ranges. The patient was discharged home with dual antiplatelettherapy.Energy drinkconsumptionisincreasingandhasbecomevery popu-lar,especiallyamongyoungpeople.Previouscasereportshadlinkeden-ergy drinks with sudden cardiac death, coronary vasospasm, reversibleposturaltachycardiasyndrome,andseriousarrhythmias,includingven-tricular fibrillation. Most of the cases were related to overuse or con-comitant alcohol intake [1–4].Almost all such commercially available drinks have the same basicstimulants, caffeine, glucoronolactone, taurine, and vitamins, and it isdifficulttoknowwhichcomponentisresponsiblefortheeffectinplate-let aggregation and endothelial function. Energy drink consumptionacutely increases platelet aggregation and decreases endothelial func-tion in healthy young adults [4]. Endothelial function acutely becomesworse after drinking energy beverage [5]. These drinks contain, amongother ingredients, large amounts of caffeine. Though these drinks con-tain many other ingredients in addition to caffeine, there is little evi-dence they bare any hazards. Caffeine in high doses is well related tovarious adverse effects, and though it has a wide therapeutic index,there are many reports of serious toxicities, even death [6].Theeffectsofenergydrinksshouldbebetterinvestigatedbecauseoftheir increasing consumption by the public and their potentially lethaleffects.References

A novel marker of inflammation in patients with slow coronary flow: lymphocyte-to-monocyte ratio

AIM Recently, lymphocyte-to-monocyte ratio (LMR) has emerged as a new indirect marker of inflammation which is associated with adverse outcomes in oncology and cardiovascular diseases. The aim of the study was to evaluate the relationship between LMR and slow coronary flow (SCF). PATIENTS & METHODS A total of 100 consecutive patients with SCF and 100 consecutive patients with normal coronary flow were enrolled in this study. RESULTS LMR was significantly lower in patients with SCF than in patients with normal coronary flow (p < 0.001). Also, LMR was negatively correlated with neutrophil-to-lymphocyte ratio and CRP levels (p < 0.001 and p = 0.005). LMR was found to be significantly and independently associated with SCF (p = 0.033). CONCLUSION LMR was negatively correlated with serum C-reactive protein and neutrophil-to-lymphocyte ratio levels.

Comparison of health-related quality of life among patients using novel oral anticoagulants or warfarin for non-valvular atrial fibrillation.

Objective: The aim of this study was to compare health-related quality of life (HRQoL) measures between novel oral anticoagulants (NOACs) and warfarin-treated Turkish patients who had been started on oral anticoagulants (OACs) due to non-valvular atrial fibrillation (AF) and to determine the effects of OACs on patient’s emotional status, anxiety and depression. Methods: A total of 182 patients older than 18 years with non-valvular AF and being treated with OACs for at least 6 months according to current AF guidelines who were admitted to outpatient clinics between July 2014 and January 2015 were included in this cross-sectional study. The exclusion criteria were receiving OACs for conditions other than non-valvular AF and being unable to answer the questionnaire. A questionnaire was administered to all participants to evaluate HRQoL, depression and anxiety. The mean differences between the groups were compared using Student’s t-test; the Mann–Whitney U test was applied for comparisons of the medians. Results: The annual number of hospital admissions was significantly higher in the warfarin group (p<0.001), and all HRQoL scores were significantly lower and Hospital Anxiety and Depression Scale (HADS) score was higher in the warfarin group (p<0.001). History of any type of bleeding was significantly higher in the warfarin group (p<0.001). However, none of the patients had major bleeding. Among patients who experienced bleeding, all HRQoL scores were significantly lower and HADS score was significantly higher (p<0.001 and p=0.002, respectively). Conclusion: Warfarin-treated patients had higher levels of self-reported symptoms of depression and anxiety and compromised HRQoL when compared with NOAC-treated patients. The results may be explained by higher rates of bleeding episodes and higher number of hospital admissions, which may cause restrictions in life while on warfarin treatment.

Endocan in Hypertension and Cardiovascular Diseases

We read with interest the article entitled ‘‘Admission Endocan Level may be a Useful Predictor for In-Hospital Mortality and Coronary Severity Index in Patients With ST-Segment Elevation Myocardial Infarction’’ by Kundi et al. They showed that high endocan levels during hospital admission are an independent predictor of a worse cardiovascular (CV) outcome and a high SYNTAX score in patients with ST-segment elevation myocardial infarction. Endocan is an immunoinflammatory marker linked to endothelial dysfunction and may be a predictor of CV disease events. Also, Cimen et al found that endocan levels in patients with microvascular angina were higher than that of the control group. Besides, Cimen et al excluded patients with the conditions such as acute coronary syndrome, history of previous myocardial infarction, coronary artery bypass grafting, percutaneous coronary intervention, secondary hypertension, severe valvular disease, congestive heart failure (New York Heart Association Classes III-IV), renal and hepatic dysfunction, any active inflammatory disease, atrial fibrillation, and malignancy. However, Kundi et al do not report any data about exclusion criteria in the study patients. They specified that only 9 patients were excluded because percutaneous coronary intervention was not performed. Likewise, hypertension rate was significantly different between the 2 groups. Hypertension is a major factor that can be associated with inflammation. We think that the authors should add this variable to the multivariate analysis.

Red Cell Distribution Width Can Predict the Significance of Angiographically Intermediate Coronary Lesions

Objective: In the present study, the association between red cell distribution width (RDW) with functional significance of intermediate coronary artery lesions was investigated. Materials and Methods: Two hundred and forty-six consecutive patients, 168 males and 78 females, who underwent fractional flow reserve (FFR) measurement for angiographically intermediate coronary stenosis (40-70% in quantitative coronary analysis) in the left anterior descending coronary artery were enrolled into the study. The functional significance of intermediate coronary artery lesions was determined by FFR measurement. An FFR value <0.75 was defined as functionally significant. Venous blood samples were taken within 48 h before the FFR measurement, and RDW levels were determined by a Coulter LH Series hematology analyzer. Logistic regression analysis was used to examine the association between functional significance in FFR measurement and other variables. Results: Of the 246 patients, 62 (25.2%) exhibited significant functional stenosis (FFR <0.75) in the FFR measurement. The mean RDW level was significantly higher in patients with significant stenosis (14.19 ± 0.73 vs. 13.69 ± 0.77, p < 0.001). In stepwise multivariate logistic regression analysis, RDW (OR = 2.489, 95% CI = 1.631-3.799, p < 0.001) and male gender (OR = 2.826, 95% CI = 1.347-5.928, p = 0.006) were independent predictors of significant functional stenosis. Conclusion: Increased RDW levels were associated with functional significance of angiographically intermediate coronary artery stenoses.

The association between mean platelet volume and spontaneous echocardiographic contrast or left atrial thrombus in patients with mitral stenosis

Objective: Although the role of platelet activation has been debated in patients with mitral stenosis (MS) and spontaneous echocardiographic contrast (SEC), data on differences in mean platelet volume (MPV) according to the presence of SEC/left atrial thrombus and the rhythm status are lacking. In this study, MPV was analyzed in patients with MS according to the presence of SEC/left atrial thrombus. Methods: Between January 2005 and March 2014, 188 symptomatic patients having moderate or severe MS (mean age, 45.0±11.7 years; female, 81.4%) with favorable valve morphology for percutaneous mitral balloon valvuloplasty (PMBV) and underwent a transesophageal echocardiogram to assess the eligibility for PMBV were retrospectively enrolled in the study. The relation between MPV and echocardiographic thromboembolic risk factors were evaluated. Independent predictors of SEC/left atrial thrombus presence were determined by multiple logistic regression analyses. Results: Among all patients, MPV did not differ according to the rhythm status or the presence of SEC/left atrial thrombus (p>0.05). Also, MPV did not vary according to the gender and presence of prior stroke in both atrial fibrillation and sinus rhythm groups (p>0.05). In correlation analysis, MPV did not show any significant correlation with the echocardiographic thrombus predictors (p>0.05). Conclusion: Using MPV with echocardiographic and clinical thrombus risk determinants for predicting individual thromboembolism risk in MS is debatable according to our results.

Predictors of neurologically favorable survival among patients with out-of-hospital cardiac arrest: A tertiary referral hospital experience

OBJECTIVE Despite recent advances in medical support and interventions, only 5% to 10% of patients with out-of-hospital cardiac arrest (OHCA) survive to discharge. In this study, factors related to neurologically favorable survival in patients with OHCA were analyzed. METHODS A total of 129 patients who were admitted to hospital with OHCA were retrospectively enrolled. RESULTS Sustained return of spontaneous circulation (ROSC) (ROSC lasting >20 min) was achieved in 29 (22.4%) patients. Percentage of cardiac arrests with ischemic etiology was significantly higher in successful ROSC group (p<0.001). In multivariate logistic regression analysis, cardiac arrest with ischemic etiology (p=0.004) and cardiopulmonary resuscitation (CPR) duration (p=0.013) were found to be independent predictors for ROSC. One-minute increment in CPR duration was associated with 1.202-fold increase in failure to achieve ROSC. Among patients with ROSC, 7 (5.4%) survived to hospital discharge, and 1-minute increment in CPR duration was associated with a 1.123-fold decrease in neurologically favorable survival (p=0.005). CONCLUSION In patients with OHCA, ischemic etiology is associated with better ROSC rate compared to other reasons for cardiac arrest, and patients with prolonged CPR are less likely to survive.

Usefulness of the Macruz Index for Predicting Successful Percutaneous Mitral Balloon Valvuloplasty in Patients with Mitral Stenosis

Objective: The aim of this study was to determine whether the Macruz index (P/P-R segment) could predict the severity of valvular involvement and the success of percutaneous mitral balloon valvuloplasty (PMBV) in patients with mitral stenosis (MS). Subjects and Methods: Sixty-one patients with MS eligible for PMBV and 72 healthy subjects (61 females and 11 males) with sinus rhythm were enrolled into this study. PMBV was performed in all patients using a percutaneous transseptal antegrade approach and a multitrack balloon technique. The P/P-R segment ratio and echocardiographic variables were measured before and 48-72 h after the procedure. The optimal cutoff point for differences in the Macruz index to determine clinical success was evaluated by receiver operating characteristic analysis by calculating the area under the curve as giving the maximum sum of sensitivity and specificity for the significant test. Results: In the patient group (mean age 42.9 ± 11.1 years), the preprocedural Macruz index was significantly higher than in the control group (2.79 ± 1.03 vs. 1.29 ± 0.11; p < 0.001). In the successful-procedure group (n = 53), the mean postindex value was significantly lower (2.12 ± 0.71 vs. 2.81 ± 1.0, p = 0.020), and the decrease in the Macruz index was significantly higher than in the unsuccessful-procedure group (p = 0.007). An index decrease of 0.105 was the best cutoff value to distinguish the successful-PMBV group from the unsuccessful- PMBV group (area under the curve = 0.888, 95% confidence interval 0.788-0.988, p < 0.001). Conclusion: The Macruz index was significantly higher in patients with MS compared to healthy subjects. A greater decrease in the Macruz index was associated with a successful PMBV.