Mehmet Fatih Özlü

Increased mean platelet volume in patients with slow coronary flow

Mean platelet volume (MPV) is an indicator of platelet activation, a central process in the pathophysiology of coronary heart disease (CAD). The importance of slow coronary flow (SCF) phenomenon results from its association with angina pectoris, acute myocardial infarction, hypertension and sudden cardiac death. The aim of this study is to evaluate the values of MPV in patients with SCF. MPV was measured in 84 consecutive patients with SCF and 88 patients with CAD and 84 control subjects. The association between thrombolysis in myocardial infarction (TIMI) frame count (TFC) and MPV level and other clinical and laboratory parameters were evaluated. There were no statistically significant differences in MPV between SCF group and CAD group. MPV was significantly higher in patients in the both SCF and CAD groups, compared with control group. The TFC for all the epicardial coronary arteries and the mean TFC were significantly higher in the SCF group than the both CAD group and control group. The mean TFC was positively and moderately correlated with MPV in the whole study population. To determine the independent predictors of mean TFC, a stepwise linear regression analysis was performed by including the parameters that were correlated with the mean TFC in the bivariate analysis. MPV level was the only independent predictor of the mean TFC (b = 0.312, p < 0.001). These findings have shown that MPV level is significantly associated with coronary blood flow and that elevated MPV level might be an independent predictor for the presence of SCF. We believe that further studies are needed to clarify the role of MPV in SCF complicatedCAD, especially in relation to angiographic and clinical parameters, before we conclude that MPV to be used as a follow-up marker during the management of relevant patients.

Serum Levels of Omentin in End-Stage Renal Disease Patients

Introduction: Cardiovascular disease is the leading cause of morbidity and mortality in hemodialysis patients. Therefore, evaluation and prevention of cardiovascular diseases in end-stage renal disease (ESRD) patients are very important. The plasma level of omentin was found to be associated with different conditions such as insulin resistance. It is one of the novel adipokines synthesized mainly in the visceral adipose tissue. In this study, we aimed to investigate the level of omentin in patients with ESRD receiving hemodialysis. Methods: The study population consisted of 59 adult chronic hemodialysis patients (30 women and 29 men) and age-matched control subjects were selected from apparently healthy subjects (28 participants; 14 women and 14 men). Blood samples were obtained before the dialysis session. Omentin concentrations were determined by using enzyme-linked immunosorbent assay. Results: Plasma levels of omentin were found to be markedly higher in ESRD patients (606.6 ± 313.0 ng/ml) than in the control group (357.5 ± 147.4 ng/ml; p < 0.0001). Also, serum omentin levels were found to be correlated with creatinine (r = 0.333, p = 0.002). Conclusions: Omentin levels were found to be elevated in patients with ESRD receiving hemodialysis. To the best of our knowledge, this is the first clinical study that demonstrated the association between omentin and ESRD.

Elevated Serum Uric Acid Predicts Angiographic Impaired Reperfusion and 1-Year Mortality in ST-Segment Elevation Myocardial Infarction Patients Undergoing Percutaneous Coronary Intervention

Background Serum uric acid (SUA) is associated with microvascular disease that could alter coronary blood flow and prognosis. We evaluated the effects of admission SUA levels on coronary blood flow and prognosis in 185 consecutive patients with ST-segment elevation myocardial infarction (STEMI) who underwent acute primary percutaneous coronary intervention (PCI). Methods Patients undergoing PCI for an acute STEMI were stratified into elevated SUA (>6.5 mg/dL) and normal SUA group (≤6.5 mg/dL). Primary end points were post-PCI myocardial blood flow and in-hospital and 1-year mortality. Results Serum uric acid level was high in 45 patients (24%) on admission. Subjects with elevated SUA had a higher prevalence of hypertension, previous myocardial infarction, multivessel disease, and Killip functional class III or higher. Corrected thrombolysis in myocardial infarction (TIMI) frame count was longer, and mean TIMI myocardial perfusion grade was higher in patients with elevated uric acid compared with controls. Patients with elevated SUA levels had higher in-hospital (6.6% vs 2.8%, P < 0.01) and 1-year mortality (11.1% vs 5.7%, P < 0.01). Major adverse cardiac events were higher in patients with elevated SUA levels both in-hospital (11.1% vs 5.7%, P < 0.01) and at 1 year (17.7% vs 10%, P < 0.05). An elevated admission SUA level also independently predicted both 1-year mortality (odds ratio, 1.41; 95% confidence interval, 1.24-2.69) and abnormal myocardial perfusion detected by TIMI myocardial perfusion grade in STEMI patients undergoing primary PCI (odds ratio, 2.14; 95% confidence interval, 1.17-4.19, respectively). Conclusions Elevated SUA level on admission independently predicts impaired myocardial flow and poor prognosis in STEMI patients undergoing primary PCI.

Prognostic Significance of Neutrophil Gelatinase–Associated Lipocalin in ST-Segment Elevation Myocardial Infarction

Objectives This study investigated the prognostic value of neutrophil gelatinase–associated lipocalin (NGAL) in patients with ST-segment elevation myocardial infarction (STEMI). Background Neutrophil gelatinase–associated lipocalin is a promising biomarker for acute kidney injury. Recently, it was concluded that NGAL may be used beyond the boundaries of renal physiopathology. It was found to be an important factor indirectly contributing to the inflammatory processes. Little is known regarding its predictive role in STEMI. Methods One hundred six consecutive patients who underwent percutaneous coronary intervention (PCI) for STEMI and control group consisted of age- and sex-matched 60 consecutive patients with chest pain admitted to the hospital for elective PCI. According to median NGAL level, patients were classified into high- and low-NGAL groups. Results Neutrophil gelatinase–associated lipocalin levels were higher in patients with STEMI compared to the elective PCI group subjects. Inhospital and 1-year mortality rates were found to be significantly greater in patients with high NGAL. In addition, inhospital and 1-year major adverse cardiovascular event rates were significantly greater in the high-NGAL group, compared to the low NGAL group. High NGAL level on admission was a significant predictor for long-term mortality and major adverse cardiovascular events. The receiver operating characteristics curve analysis further illustrated that NGAL level on admission is a strong indicator of mortality, with an area under the curve of 0.76 (95% confidence interval, 0.62–0.89). Conclusions High NGAL levels may be associated with poor prognosis after PCI in patients with STEMI. However, further studies with larger numbers of patients and longer follow-up are required to evaluate the usefulness of plasma NGAL level for predicting prognosis of STEMI.

Elevated plasma asymmetric dimethylarginine level in acute myocardial infarction patients as a predictor of poor prognosis and angiographic impaired reperfusion

OBJECTIVES We aimed to investigate the effects of admission asymmetric dimethylarginine (ADMA) levels on myocardial perfusion and prognosis in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). BACKGROUND ADMA, an endogenous inhibitor of endothelial nitric oxide synthase, was found to be elevated in plasma of patients with cardiovascular risk factors. METHODS 168 consecutive patients undergoing primary PCI for STEMI <12 h after symptom onset and 75 healthy age and sex matched volunteer controls were enrolled in the study. Patients with STEMI were grouped into tertiles according to their admission plasma ADMA levels. Major adverse cardiac events during hospitalization or at one-year clinical follow-up were evaluated. Also angiographic impaired reperfusion was assessed by 3 different methods after PCI: angiographic thrombolysis in myocardial infarction (TIMI) flow, TIMI frame count and TIMI myocardial perfusion grade (TMPG). RESULTS Plasma level of L-arginine were lower in patients with STEMI than in the control group subjects, whereas plasma ADMA levels were increased in the STEMI patient group. The rate of impaired angiographic reperfusion increased across the tertile groups. Also one-year mortality rates showed a significant increase across the tertile groups (4% vs. 10% vs. 20%, p<0.01). Using multiple Cox regression analysis, only TIMI risk score, left ventricle ejection fraction (LVEF), abnormal TMPG, and increased ADMA values on admission emerged as independent predictors of one-year mortality. The ROC analysis indicated an optimal cut-point of ≥1.37 μmol/L, which detects one-year mortality with a negative predictive value of 96%. CONCLUSIONS In STEMI patients undergoing primary PCI, high admission ADMA levels were found to be associated with impaired myocardial perfusion and increased one-year mortality. Therefore admission ADMA level detection may be helpful in identifying the patients at a greater risk of impaired myocardial perfusion and poor prognosis.

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa in a patient with Takayasu's arteritis

An asymptomatic 35-year-old woman with Takayasu’s arteritis, moderate aortic regurgitation, left ventricular (LV) hypertrophy and hypertension was referred to the echocardiography laboratory at the Yuksek Ihtisas Hospital (Ankara, Turkey) for a routine clinical follow-up. Transthoracic echocardiography revealed a suspected aneurysm in the subaortic region adjacent to the left sinus of Valsalva (Figure 1A). Subsequent three-dimensional real-time transthoracic echocardiography clearly demonstrated a pseudoaneurysm in the mitral-aortic intervalvular fibrosa (MAIVF) (Figure 1B). Specific echocardiographic features identified the lesion as a pseudoaneurysm: expansion in systole and collapse in diastole (Figure 1C), and communication between the sac and the LV outflow tract (Figure 1B). Figure 1) A Transthoracic echocardiography showing suspected aneurysm in the subaortic region adjacent to the left sinus of Valsalva (arrowhead). B Three-dimensional, real-time transthoracic echocardiography showing a pseudoaneurysm in the mitral-aortic intervalvular ... The MAIVF is the fibrous junction between the noncoronary and left coronary cusps of the aortic valve and the anterior mitral leaflet (1). Most pseudoaneurysms of the MAIVF form as complications of aortic valve endocarditis or aortic root surgery (2). The prognosis is grave because of the high risks of rupture, peripheral embolization and destruction of the aortic or mitral valves (1–3). Of note, the patient had not undergone cardiac surgery, and tests showed no evidence of infective endocarditis. It is known that a pronounced shear effect on tissues near MAIVF can lead to pseudoaneurysm formation (3). In Takayasu’s arteritis, the MAIVF is exposed to high LV intracavitary pressure due to elevated central aortic pressure. Pseudoaneurysm of the MAIVF is unusual in the setting of Takayasu’s arteritis. Surgical correction is life-saving, so clinicians should keep in mind that such lesions can occur in this patient group. Three-dimensional real-time transthoracic echocardiography is an excellent, noninvasive way to accurately diagnose pseudoaneurysms of the MAIVF.

Predictive value of mean platelet volume in young patients with non-ST-segment elevation acute coronary syndromes: a retrospective observational study

OBJECTIVE Platelets play an important role in both initiation and propagation of acute coronary syndromes. We sought to evaluate the predictive value of mean platelet volume (MPV) in young patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS). METHODS This is a retrospective observational study; evaluating the MPV values of 79 NSTE-ACS patients aged under 45 years and 45 control subjects having normal coronary anatomy. NSTE-ACS group was composed of 41 non-ST elevation myocardial infarction (NSTEMI) and 38 unstable angina pectoris (USAP) patients. MPV was measured using an automated hematologic analyzer called Coulter counter. The predictive value of MPV was evaluated using logistic regression analysis and comparison of MPV between NSTE-ACS and control groups was performed by Mann-Whitney U test. RESULTS The MPV was found to be significantly higher in the NSTE-ACS compared with control group (8.49±1.22 versus 7.78±0.65 fL, p=0.001). In logistic regression analysis, MPV was found to be an independent predictor of NSTE-ACS (OR=3.1, 95% CI 1.2-8.2, p=0.022). The MPV values of NSTEMI group were not significantly different from USAP group (8.78±1.38 versus 8.17±0.95 fL, p=0.66). Similarly, the MPV values of the 3 groups (Control, USAP and NSTEMI) were found to be significantly different (7.78±0.65, 8.18±0.95, 8.78±1.38 fL respectively, p=0.001). CONCLUSION In conclusion, MPV was found to be elevated in NSTE-ACS patients compared with control subjects in young population. In addition, increased MPV was established to be an independent predictor of NSTE-ACS.

Effect of Serum Gamma-Glutamyl Transferase Levels on Myocardial Perfusion and Long-Term Prognosis After Primary Angioplasty in Patients With Acute ST-Elevation Myocardial Infarction

Background Gamma-glutamyl transferase (GGT) level was found to be elevated in plasma of patients with cardiovascular risk factors. The aim of our study was to assess the relationship between serum GGT levels and the occurrence of no-reflow as well as to evaluate the prognostic value of GGT in ST-segment elevation myocardial infarction (STEMI) population. Methods and Results One hundred sixty-eight consecutive patients with STEMI who underwent percutaneous coronary intervention (PCI) were enrolled in the study. Patients with STEMI were grouped into tertiles according to their admission serum GGT levels. No-reflow after PCI was assessed both angiographically (thrombolysis in myocardial infarction [TIMI] flow and myocardial blush grade) and electrocardiographically (ST resolution). Gamma-glutamyl transferase levels were higher in patients with STEMI compared to the elective PCI group subjects. Patients with angiographically (TIMI flow ⩽2 or TIMI flow 3 with final myocardial bush grade ⩽2 after PCI) and electrocardiographically (ST resolution <30%) detected no-reflow were increased in number across the GGT tertiles. In addition, 1-year mortality rates showed a significant increase across the tertile groups (4% vs 11% vs 23%, P < 0.01). Multivariable logistic regression analysis revealed that GGT levels on admission were a significant predictor of long-term mortality of myocardial blush grade–detected no-reflow phenomenon. High GGT level on admission was a significant predictor for long-term mortality and major adverse cardiac events. Conclusions In patients with STEMI undergoing primary PCI, high GGT levels at admission were found to be associated with no-reflow phenomenon and increased long-term mortality.

Lower fetuin-A predicts angiographic impaired reperfusion and mortality in ST-elevation myocardial infarction.

Aims Fetuin-A is an anti-inflammatory negative acute-phase glycoprotein, synthesized by the liver. In this study, we aimed to investigate the effects of admission fetuin-A levels on coronary and myocardial blood flow and short- and long-term prognosis in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention. Methods and Results One hundred eighty consecutive patients admitted with diagnosis of STEMI and 55 healthy age- and sex-matched volunteer controls were enrolled in the study. Patients with STEMI were divided into 2 groups in respect to thrombolysis in myocardial infarction myocardial perfusion grade after primary PCI: with thrombolysis in myocardial infarction myocardial perfusion grade 0-1-2 and thrombolysis in myocardial infarction myocardial perfusion grade 3. Serum levels of fetuin-A were lower in patients with STEMI than in the healthy group subjects. In-hospital and 1-year deaths were significantly higher in patients from the abnormal perfusion group. In-hospital major adverse cardiac event (MACE) and 1-year follow-up MACE also were significantly higher in patients from the abnormal perfusion group. The receiver-operating characteristic analysis indicated an optimal cut point of less than 200 μg/mL, which detects 1-year mortality with a negative predictive value of 95%. The 1-year mortality rate and 1-year MACE were significantly higher in patients with low fetuin-A level as compared with those with high fetuin-A level. Conclusions Because low-admission fetuin-A levels are associated with impaired coronary flow in STEMI patients undergoing primary percutaneous coronary intervention, admission fetuin-A level detection may be helpful in identifying the patients at a greater risk of poor coronary blood flow and worse short- and long-term prognosis.

Detection of subclinical atrial dysfunction by two-dimensional echocardiography in patients with overt hyperthyroidism.

BACKGROUND Hyperthyroidism is an important cardiovascular risk factor in the development of atrial fibrillation and heart failure. Increased atrial electromechanical intervals are used to predict atrial fibrillation, measured by tissue Doppler imaging (TDI). AIMS To evaluate atrial electromechanical delay (EMD) and left atrial (LA) mechanical function in patients with overt hyperthyroidism. METHODS Thirty-four patients with overt hyperthyroidism and 34 controls were included. A diagnosis of overt hyperthyroidism was reached with decreased serum thyroid-stimulating hormone (TSH) and increased free T4 (fT4) concentrations. Using TDI, atrial electromechanical coupling (PA) was obtained from the lateral mitral annulus (PA lateral), septal mitral annulus (PA septum) and right ventricular tricuspid annulus (PA tricuspid). LA volumes (maximum, minimum and presystolic) were measured by the disks method in apical four-chamber view and indexed to body surface area. LA active and passive emptying volumes and fractions were calculated. RESULTS LA diameter was significantly higher in hyperthyroid patients (P=0.001). LA passive emptying volume and fraction were significantly decreased in hyperthyroid patients (P=0.038 and P<0.001). LA active emptying volume and fraction were significantly increased in hyperthyroid patients (P<0.001 and P<0.001). Left and right intra-atrial (PA lateral-PA septum and PA septum-PA tricuspid) and interatrial (PA lateral-PA tricuspid) EMDs were significantly higher in hyperthyroid patients (29.2 ± 4.4 vs 18.1 ± 2.6, P<0.001; 18.7 ± 4.3 vs 10.6 ± 2.0, P<0.001; and 10.5 ± 2.9 vs 7.1 ± 1.2, P<0.001, respectively). Stepwise linear regression analysis demonstrated that fT4 and TSH concentrations were independent predictors of interatrial EMD (β=0.436, P<0.001 and β=-0.310, P=0.005, respectively). CONCLUSION This study showed prolonged atrial electromechanical intervals and impaired LA mechanical function in patients with overt hyperthyroidism, which may be an early sign of subclinical cardiac involvement and dysrhythmias in overt hyperthyroidism.