Kamuran Kalkan

Neutrophil-to-Lymphocyte Ratio Predicts Contrast-Induced Nephropathy in Patients Undergoing Primary Percutaneous Coronary Intervention

We investigated the relationship between baseline neutrophil-to-lymphocyte ratio (NLR) and contrast-induced nephropathy (CIN) in patients with ST-segment elevation myocardial infarction (STEMI). Consecutive patients diagnosed with STEMI (n = 691) who underwent primary percutaneous coronary intervention (p-PCI) were included in the study. The CIN was defined as an increase in serum creatinine concentration ≥25% over baseline at 48 hours. Both NLR and C-reactive protein levels were significantly higher in the CIN group. There was a stronger correlation in patients with a known history of chronic kidney disease and in patients with a history of diabetes mellitus (DM). Advanced age, DM, low baseline glomerular filtration rate, reduced postprocedural ST resolution, high amount of contrast media, high NLR, and low left ventricular ejection fraction were independent predictors of CIN. The NLR may be used as a simple and reliable indicator of CIN in patients with STEMI who underwent p-PCI.

The Role of the Nonspecific Inflammatory Markers in Determining the Anatomic Extent of Venous Thromboembolism

We aimed to investigate the relationship between the extent of venous thromboembolism (VTE) and nonspecific inflammatory markers such as neutrophil to lymphocyte ratio (NLR) and high-sensitivity C-reactive protein (hs-CRP). We retrospectively enrolled 77 patients with VTE (distal deep vein thrombosis [DVT], n = 19; proximal DVT, n = 32; and pulmonary thromboembolism [PTE], n = 26) and 34 healthy controls. In the performed analysis of variance, the levels of white blood cell, NLR, and hs-CRP were clearly different among the groups (control, distal and proximal DVT, and PTE) (P < .001). Especially, a significant increase from the control group to the DVT and PTE was observed in the analysis made for NLR. In the performed receiver–operating characteristic curve analysis, area under curve (AUC) = 0.849 and P < .001 were detected for NLR > 1.84. For this value, the sensitivity and specificity were determined as 88.2% and 67.6%, respectively. The NLR is an inexpensive and a readily available marker that may be effective in determining the extent of VTE, and it is useful for risk stratification in patients with VTE.

Determinants of Angiographic Thrombus Burden in Patients With ST-Segment Elevation Myocardial Infarction:

Aims: We aimed to investigate the determinants of angiographic thrombus burden in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (pPCI). Methods: The study population consisted of 662 patients with nonanemic STEMI who underwent pPCI. Clinical, laboratory, and demographic properties of the patients were recorded. Baseline hematologic indices were measured at the time of admission. Angiographic coronary thrombus burden was scored based on thrombolysis in myocardial infarction (TIMI) thrombus grades. After wiring and/or small balloon dilation, patients with thrombus burden grades 4 and 5 were defined as high thrombus burden, and patients with thrombus burden <grade 4 was defined as low thrombus burden. Result: Patients with high thrombus burden had more family history of coronary artery disease, longer pain to balloon time, higher Killip class (≥II), higher neutrophil to lymphocyte ratio, red cell distribution width (RDW), baseline creatine kinase-MB fraction (CK-MB) and baseline troponin, higher peak CK-MB, and peak troponinbut lower triglycerides. Angiographically, patients with high thrombus burden had longer lesion in the infarct-related artery, less frequent direct stenting, lower epicardial and myocardial perfusion, more frequent distal embolization, and more frequent electrocardiographic and angiographic no reflow. In multivariate logistic regression analysis, only RDW (odds ratio: 1.29, 95% confidence interval 1.19-1.39, P < .001) was determined as independent predictor. The area under the receiver–operating characteristic curve of the RDW was 0.733 (0.690-0.776, P < .001) to predict high TIMI thrombus burden. Conclusion: Present study results demonstrated that high thrombus burden in patients with STEMI was associated with impaired postprocedural epicardial and myocardial perfusion and higher no reflow and distal embolization; and increased RDW values were independent predictors of coronary thrombus burden.

Relation of coronary collateral circulation with red cell distribution width in patients with non-ST elevation myocardial infarction.

Objectives: We aimed to investigate the relationship between red cell distribution width (RDW) value and coronary collateral circulation (CCC) in patients with non-ST elevation myocardial infarction (NSTEMI). Methods: The study population consisted of 322 consecutive patients with NSTEMI. The patients were classified into impaired CCC (group 1, Rentrop grades 0-1) or good CCC (group 2, Rentrop grades 2-3). Baseline RDW was measured as part of the automated complete blood count. Results: The RDW values were significantly higher in patients with impaired CCC than in those with good CCC (17.2 ± 2.3 vs 14.5 ± 2.5, P < .001). In multivariate logistic regression analysis, RDW (odds ratio: 1.52, 95% confidence interval: 1.30-1.78, P < .001), baseline creatine kinase MB (CK-MB), and absence of preinfarction angina were found to be the independent predictors of impaired CCC. In receiver–operating characteristic curve analysis, the RDW value >15.5 yielded an area under curve value of 0.783, with 77% sensitivity and 73% specificity. Conclusions: Our study results demonstrated that, high RDW, high CK-MB, and absence of preinfarction angina were found to be independent predictors of impaired CCC.

Relation of uric acid and contrast-induced nephropathy in patients undergoing primary percutaneous coronary intervention in the ED

OBJECTIVES To investigate the predictive role of serum uric acid (SUA) levels measured in the emergency department (ED) to monitor contrast-induced nephropathy (CIN) and correlation with severity of nephropathy in patients undergoing primary percutaneous coronary intervention (PCI). METHOD The patients who were admitted to our ED and underwent primary PCI were enrolled retrospectively. Their baseline characteristics including SUA and creatinine levels in the ED and their creatinine levels 48 hours after PCI were noted. Nephropathy was graded as follows: grade 0, ΔCr ≤25% and ≤0.5 mg/dL; grade 1, ΔCr >25% but ≤0.5 mg/dL; and grade 2, ΔCr >0.5 mg/dL. A multiple logistic regression analysis was used to define the independent predictors of CIN. RESULTS Of a total of 744 patients, CIN was observed in 12.5% (n = 93). Serum uric acid levels were significantly higher in the CIN (+) group compared with the CIN (-) group (6.09 ± 2.01 mg/dL vs 4.89 ± 1.32 mg/dL, respectively; P < .001). Patients with grade 0 CIN had significantly lower SUA levels than did those with grades 1 and 2 (4.89 ± 1.32 mg/dL vs 5.88 ± 1.99 and 6.41 ± 2.02 mg/dL, respectively; P < .001), but there was no significant difference between grade 1 and grade 2 CIN cases in terms of SUA levels (5.88 ± 1.99 mg/dL vs 6.41 ± 2.02 mg/dL, P = .10). The cutoff value for SUA was 5.05 mg/dL for the prediction of CIN (area under the curve, 0.685; P < .001; sensitivity, 66%; specificity, 60%) in the population. CONCLUSIONS The SUA level is a simple independent early predictor of CIN in patients who underwent primary PCI, and early detection may help prevent the progression of CIN.

Intracranial hemorrhage with electrocardiographic abnormalities and troponin elevation

Electrocardiographic (ECG) abnormalities and cardiac troponin I elevation are seen in addition to the classic clinical symptoms and signs of subarachnoid hemorrhage (SAH). We aimed to show that, in patients with ST elevation, troponin elevation, and altered consciousness, the reason may be SAH. A 36-year-old man presented to emergency service with ECG abnormalities, high level of cardiac troponin I, and neurologic symptoms. In the patients initial ECG, there were sinus arrhythmia, bradycardia, T-wave inversions inferiorly, and concave ST elevations in V1 to V4. Three hours later, his ECG showed increased ST-segment elevations with normal heart rate. The patients troponin I value was 10 mg/L. Ejection fraction was 60%, and there were no wall motion abnormalities on echocardiography. Computed tomographic scan of the brain demonstrated SAH with falx sign and midline cerebellar hematoma (3 × 4 cm in size) in the occipital region. The patient died on the 10th day of follow-up because of severe metabolic acidosis, multiorgan failure, and bradycardia. Cardiac evaluation is recommended in patients with intracranial hemorrhage in many studies. In our opinion, if there are neurologic symptoms or signs in patients diagnosed as acute myocardial infarction with ECG changes and troponin elevation, requesting threshold of brain computed tomography should be low before the thrombolytic therapy.

Bilirubin Levels and Thrombus Burden in Patients With ST-Segment Elevation Myocardial Infarction

We investigated whether serum bilirubin level (a marker of heme oxygenase activity) is a predictor of thrombus burden in patients with acute myocardial infarction. Patients (n = 229; male 72.9%; mean age 63 ± 13.4 years) who were admitted with ST-segment elevation myocardial infarction (STEMI) were enrolled. Patients were divided into 2 groups. Group 1 was defined as low thrombus burden and group 2 was defined as high thrombus burden. Patients with high thrombus burden had higher total bilirubin levels (14.4 [4.3-22.9] vs 7.7 [2.4-20.3] µmol/L, P ≤ .001), (0.84 [0.25-1.34] vs 0.45 [0.14-1.19] mg/dL P ≤ .001) and direct bilirubin levels (3.1 [2.1-8.4] vs 1.7 [0.5-6.5] µmol/L, P ≤ .001), (0.18 [0.03-0.49] vs 0.10 [0.03-0.38] mg/dL, P ≤ .001). At multivariate analysis, total bilirubin (odds ratio: 1.05, 95% confidence interval: 1.03-1.08, P ≤ .001) was the independent predictor of high thrombus burden. In conclusion, total bilirubin level is independently associated with high thrombus burden in patients with STEMI.

Total Bilirubin Levels Predict Subclinical Atherosclerosis in Patients With Prediabetes

Bilirubin may have important antiatherosclerotic effects. Prediabetes (PD), the intermediate stage before diabetes mellitus, is associated with increased cardiovascular morbidity and mortality. We evaluated the relationship between serum bilirubin levels and carotid intima–media thickness (cIMT), as a surrogate marker of subclinical atherosclerosis, in patients with PD. We enrolled 170 consecutive patients with PD. The patients underwent ultrasonography to evaluate cIMT. The patients were divided into groups according to cIMT values (<0.9 vs ≥0.9 mm). The patients with cIMT ≥ 0.9 mm had significantly higher diastolic blood pressure, neutrophil–lymphocyte ratio (NLR), and glycated hemoglobin values compared with patients having cIMT < 0.9 mm, whereas total and direct bilirubin values were significantly lower in this group. Multivariate regression analyses revealed NLR and total bilirubin as the independent predictors of subclinical atherosclerosis. The present study demonstrated that NLR and lower total bilirubin levels were independent predictors of subclinical atherosclerosis in patients with PD. Simple measures such as NRL and total bilirubin may provide predictive information regarding the risk of cardiovascular disease in patients with PD.

Massive pulmonary embolism mimicking electrocardiographic pattern of Brugada syndrome.

Brugada syndrome is an inherited heart disease without structural abnormalities that is thought to arise as a result of accelerated inactivation of Na channels and predominance of transient outward K current to generate a voltage gradient in the right ventricular layers. Brugada syndrome occurs in patients with structurally normal heart and predisposes patients to malignant ventricular arrhythmias. Acute pulmonary embolism has been associated with a variety of electrocardiograms,and rarely, it may mimic electrocardiographic pattern of Brugada syndrome and this condition was defined as Brugada phenocopy.

The Role of Serum Bilirubin Levels in Predicting Troponin Positivity in Non-ST-Segment Elevation Acute Coronary Syndrome.

Data are scant regarding serum bilirubin levels in non-ST-segment elevation acute coronary syndrome (NSTE-ACS). In this study, we evaluated the role of serum bilirubin levels in NSTE-ACS. We enrolled 782 patients who presented to the emergency department with acute chest pain. Patients were divided into 2 groups based on the troponin positivity. Patients with NSTE-ACS who had troponin positivity were included in group 1 (n = 382), and group 2 consisted of the control patients (n = 400). Direct bilirubin (DB) levels (group 1: 0.31 ± 0.37 mg/dL, group 2: 0.20 ± 0.25 mg/dL, P < .001) and total bilirubin (TB) levels (group 1: 0.78 ± 0.56 mg/dL, group 2: 0.62 ± 0.45 mg/dL, P < .001) were significantly higher in group 1. There was a significant and moderate correlation between serum bilirubin levels and admission troponin values (r = .34, P < .001 for TB and r = .42, P < .001 for DB). These results show that serum bilirubin levels were associated with troponin positivity in patients with NSTE-ACS.