Nadi Arslan

Are maximum P wave duration and P wave dispersion a marker of target organ damage in the hypertensive population

BackgroundHigh blood pressure, left ventricular hypertrophy and diastolic dysfunction may cause hemodynamic and morphological changes in the left atrium, consequently instability and heterogeneity in atrial conduction. This is seen as an increase in maximum P wave duration (Pmax) and P wave dispersion (PD) on the electrocardiogram (ECG). P wave dispersion on ECG has been encountered as a risk factor for atrial fibrillation (AF). The aim of this study is to examine whether PD and Pmax can be used as a non-invasive marker of target organ damage (LVH and diastolic dysfunction) in a hypertensive population.Material and methodsThe study registered a total of 120 cases (mean age 46.9 ± 10.6 years; 58 [48.3%] males and 62 [51.7%] females), of whom 60 were patients diagnosed as essential hypertension (group 1), and 60 were healthy individuals, who constituted the control group (group 2). Systolic and diastolic functions of all cases were evaluated by echocardiography, and maximum P wave duration (Pmax), and PD was calculated.ResultsMaximum P wave duration was 91.6 ± 10.2 ms in group 1, and 64 ± 10.2 ms in group 2 (p < 0.01), while PD was 56.1 ± 5.8 ms in group 1, and 30.3 ± 6.6 ms in group 2 (p < 0.01). Blood pressure, left atrium diameter, DT, IVRT, and E/A ratio, as well as left ventricular mass index increased markedly in group 1.ConclusionHigh blood pressure, LVH, diastolic dysfunction and increased left atrium diameter and volume shows parallelism in hypertensive cases. These physiopathological changes may cause different and heterogeneous atrial electrical conduction. This led to a marked increase in Pmax and PD in our cases. Thus, the results support the hypothesis that PD can be used as a non-invasive marker of target organ damage (LVH and LV diastolic dysfunction) in the hypertension population.

The effect of long-term clopidogrel use on neointimal formation after percutaneous coronary intervention.

ObjectiveThe purpose of this study was to evaluate the long term effect of clopidogrel-based antiplatelet therapy on neointimal formation. MethodsThis study comprised 78 patients with typical stable angina pectoris or documented myocardial ischaemia, and with only one angiographic lesion in one native coronary artery undergoing successful stent implantation without predilatation with C-reactive protein levels ≤5 mg/l at 72 h after the procedure. All patients received dual antiplatelet therapy with 75 mg/day clopidogrel and 300 mg/day aspirin for four weeks. Clopidogrel was switched to isochronous placebo in half of the patients (n=39) at the end of the fourth week. This allocation was maintained for 20 weeks, and at week 24 of the study, coronary angiography and intravascular ultrasound imaging were performed again in all cases in order to evaluate the changes that had occurred in the in-stent neointimal formation; rates of restenosis were also recorded ResultsAt the end of the follow-up period, angiographic stenosis diameter and restenosis rates were smaller in the clopidogrel group than in the placebo group (23.3% versus 35.6%, p=0.05 and 5.12% versus 10.25%; p=0.03 respectively); the intravascular ultrasonographic neointimal cross sectional area was also smaller in the clopidogrel group (3.6±2.7 mm2 versus 5.2±2.5 mm2, p=0.03). ConclusionsLong-term clopidogrel administration significantly reduced neointimal formation at the stent site as well as reducing major clinical events in patients who did not develop high-risk systemic inflammatory response after percutaneous coronary intervention.

Predictive value of C-reactive protein in patients with unstable angina pectoris undergoing coronary artery stent implantation.

In-stent restenosis is a major problem following coronary stent implantation, and inflammation plays an active role. We evaluated the effectiveness of the inflammatory marker C-reactive protein (CRP) as a predictor of in-stent restenosis after successful stent implantation, in 86 patients with unstable angina pectoris. Plasma CRP was measured in all patients before the procedure, and at 48-72 h and 1, 2 and 3 months post-procedure. An angiographic loss of 50% at follow-up was accepted as in-stent restenosis. We found negative and positive predictive values of the pre-procedural plasma CRP for determining 6-month in-stent restenosis of 34% and 61%, respectively. We also found a strong correlation between the 3-month post-procedural CRP value and 6-month in-stent restenosis; the negative and positive predictive values being 8% and 76%, respectively. In conclusion, we showed that a plasma CRP value > 3 mg/l in the third month after coronary stent implantation was a strong predictor of angiographic in-stent restenosis.

Effects of tirofiban on acute systemic inflammatory response in elective percutaneous coronary interventions

SUMMARY Objective: In this study the effect of a specific glycoprotein IIb/IIIa inhibitor, tirofiban [which also has antiplatelet activity on acute systemic inflammatory responses (IR) during elective percutaneous coronary intervention (PCI)] was evaluated. Patients and methods: Patients with stable angina pectoris and similar baseline characteristics who angiographically had a single lesion in their coronary arteries with a PCI performed on that lesion were enrolled in the study. One group of patients (control group, n = 52) received 0.9% NaCl (15 mL/h for 24h) and the other group (tirofiban group, n = 55) had tirofiban (10|ig/kg bolus infusion in 3min and 0.15jj,g/kg/mir for 24h) in addition to stenting without pre-dilatation. The effect of interventional procedure on levels of cardiac troponin T (cTnT) and several parameters of acute IR (leukocytes, fibrinogen, C-reactive protein, interleukin-1, interleukin-6, interleukin-8 and tumor necrotizing factor-α) was assessed on blood samples obtained from all patients before PCI and at pre-specified time points after PCI. Results: During the follow-up after PCI, the number of patients becoming cTnT-positive (> 0.1 ng/mL) was greater in the control group [12 (23%) patients vs. 3 (5%) patients, p = 0.01]. However, both groups had changes (generally observed as elevations) in their levels of all inflammatory parameters during the study and C-reactive protein, interleukin-6 and tumor necrotizing factor-α levels were elevated significantly. Yet, no significant difference occurred between groups due to these changes in any phase of the study (p > 0.05). Conclusions: Based on the findings of this study, it was concluded that although tirofiban limits development of myocardial necrosis during elective PCI, it does not directly affect the acute systemic inflammatory responses.

Atorvastatin affects C-reactive protein levels in patients with coronary artery disease

SUMMARY Background: Elevated levels of C-reactive protein (CRP) are considered to be one of the indicators of poor prognosis in coronary artery disease (CAD). The aim of this study was to evaluate anti-inflammatory effects of atorvastatin in patients with CAD by measuring serum CRP levels. Methods: After measuring the baseline levels of CRP and lipid fractions, the patients were divided into two groups. In Group A (n = 46), atorvastatin (20 mg/day) was administered in addition to classic antianginal treatment (beta-blocker, nitrate and aspirin). In Group B (n = 32), the usual antianginal treatment was continued. Following 4 weeks of treatment the same measurements were repeated. Results: In Group A, CRP decreased from 20.3 mg/dl (95% CI, 9-31.8) to 10.8 mg/dl (95% CI, 2.7-18.9) (p < 0.001). In Group B, CRP decreased from 17 mg/dl (95% CI, 13.1-21) to 12.8 mg/dl (95% CI, 9.7-15.9) (p < 0.01). The decrease in group A was more than in group B (p = 0.003). Conclusions: In patients with CAD, atorvastatin exerted an anti-inflammatory effect represented by decreasing CRP levels. This effect was independent of the change in low density lipoprotein cholesterol (LDL-C) or high density lipoprotein cholesterol (HDL-C) levels.

Oral Mycophenolate Mofetil Prevents In-Stent Intimal Hyperplasia Without Edge Effect:

Neointimal hyperplasia is in the forefront in in-stent restenosis. Prevention of in-stent restenosis is possible by reducing and inhibiting the hyperplasia of smooth muscle cells. The authors planned this study to test the hypothesis that when administered orally, mycophenolate mofetil (MMF) could inhibit in-stent neointimal hyperplasia. The study included 14 New Zealand rabbits. The rabbits were allocated to 2 different groups: Group 1 included 7 rabbits that were given MMF, 40 mg/kg/day by oral route. Group 2 included 7 rabbits that were not given MMF after the stenting. Sampling materials were taken before and after stenting by incising the artery so as to cover a 5-mm area. The samples taken from the edge of the stent in Group 1 showed focal neointimal cell proliferation, but it was less than that from the control group. Neointimal thickness was 0.048 ±0.009 mm and neointimal area was 0.0925 ±0.019 mm2. Apparent neointimal cell proliferation and thickening of the intimal layer were observed in Group 2. Neointimal thickness at the stent edge was 0.147 ±0.051 mm and the neointimal area was 0.154 ±0.023 mm2. The differences between groups in terms of neointimal thickness and neointimal area were statistically significant (p=0.001 for thickness and p=0.001 for area). In-stent artery samples of Group 1 showed that some subjects had no neointimal cell proliferation, while others had very limited focal intimal thickening. Neointimal thickening was 0.071 ±0.003 mm and neointimal area was 0.073 ±0.003 mm2. In Group 2 apparent, and mostly focal, neointimal cell proliferation and formation of intimal layer were observed in the stent. Neointimal thickening was 0.154 ±0.069 mm and neointimal area was 0.279 ±0.059 mm2. The comparison between groups showed significant differences (p=0.011 for thickness and p=0.001 for area). It was established in the third month that endothelialization was completed in both groups. Oral MMF decreased in-stent intimal hyperplasia without edge effect. It was concluded that for the prevention of in-stent restenosis, studies should be conducted for using systemic immunosuppressive treatments in humans as well.

Use of excimer laser for thrombus containing lesion.

The presence of thrombus in the lesion before balloon angioplasty increases the complications arising from mechanical intervention. It is known that the use of Gp llb/llla receptor blockers before the intervention enhances the reliability of the procedure. Laser thrombolysis was applied to a patient who underwent coronary angiography due to recurrent chest pain after thirty six hour administration of tirofiban and who was found to have a thrombus so large as to block the distal vessel bed of the right coronary artery. Following the procedure, the entire thrombus was broken down and Grade III distal myocardial perfusion was achieved. This case is important in demonstrating that laser application is a viable alternative in such instances, especially considering that intervention in acute coronary syndromes is on the increase and cardiologists will frequently encounter such cases.

Excimer Laser Coronary Angioplasty in Acute Myocardial Infarction

We evaluated the short-term results of percutaneous excimer laser angioplasty in acute myocardial infarction. Of the 18 patients studied, 2 were female and 16 male with a mean age of 56.6 ± 12.1 years. Thrombolysis in myocardial infarction grades 0, 1, and 2 flow was observed in 10, 5, and 3 cases, respectively, prior to the procedure. The degree of stenosis was 97.9% ± 5.1%. The lesion was crossed with a laser catheter in all cases, using a mean number of 808 ± 384 laser pulses. Type C dissection developed in only 1 case (6%). Except for this case, distal flow was grade 3 in all the patients. Following the procedure, ST segment resolution exceeding 70% was achieved in 14 cases (78%) within the first 90 minutes. The success rate of laser ablation was 94% (17 patients). Stent implantation was performed in all the cases. In conclusion, laser angioplasty is an effective and reliable treatment for acute myocardial infarction.

Direct stenting application in acute coronary syndromes

Although published reports about direct stenting in treating stable coronary artery disease have been increasing, the number of studies regarding direct stenting for acute coronary syndrome is limited. In this study, we report immediate and mid-term results of patients who underwent direct stenting for treating acute coronary syndrome. The average lesion length was 12.1 ± 3.3 mm. The preprocedure average minimum luminal diameter (MLD) was 0.67 ± 0.33 mm. Post-procedure average MLD was 3.19 ± 0.42 mm. In 35 of the 36 cases (97%), the stent delivery system crossed the lesion and was implanted successfully. In one case, an acute occlusion, which was treated by percutaneous transluminal coronary angioplasty (PTCA), occurred. The rate of procedure success was 94%. The amount of contrast media used was 88 ± 16 ml and duration of radiation exposure was 9 ± 2 min. Control angiography was performed in 28 out of 35 cases (80%). Seven patients who did not consent to coronary angiography were asymptomatic and had negative exercise tests. MLD was 2.66 ± 0.53 mm after a six month follow-up. The clinical and angiographic restenosis rates were 14% (5/35) and 18% (5/28), respectively. Three of the five cases of restenosis were treated by excimer laser coronary angioplasty (ELCA) and PTCA and the other two were treated with PTCA only. Target lesion revascularization rate was 14% (5/35). The rate of major adverse cardiac events (MACE) was 17% (6/35) after the six month follow-up period. Based on these results, we conclude that direct stenting for acute coronary syndrome is safe if the lesion is determined to be suitable.

A single center experience with the newly designed R Stent in small coronary vessels.

BACKGROUND: Over the past 10 years stents have been used more frequently for the treatment of de novo coronary artery stenosis. Initally these devices were used primarily in coronary arteries with diameters ranging from 3.0 to 4.0 mm. Traditionally, coronary arteries less than 3.0 mm in diameter were treated with only balloon angioplasty, due to the unavailablity of flexible, low profile, small diameter stents. In the past three years, many stents have been designed to be implanted in small coronary arteries. OBJECTIVE: The objective of this study was to evaluate the safety and feasiblity of the R Stent in patients with coronary lesions located in coronary arteries with a reference diameter 2.5-3.0 mm. METHODS AND RESULTS: Between November 1998 and September 1999, 32 patients with stable (37%) and unstable (63%) angina treated with the R Stent were included in this study. The treated lesions were in the right coronary artery (RCA) ( n = 13), left cirumflex coronary artery (LCX) ( n = 10), and left anterior descending coronary artery (LAD) ( n = 9). Of these lesions thirteen were anatomically complex. Stent deployment was successful in 97% with one crossing failure in a patient with a vessel tortuosity of greater than 75 degrees of the circumflex artery. No post-procedual major adverse cardiac and cerebrovascular event (MACCE) occurred within 30 days of stent implantation. After the procedure, patients were scheduled for a two-week telephone follow-up and a one-month clinical evaluation. At 30 days, only one patient (3%) experienced the recurrence of angina Canadian cardiovascular society classification ((CCS) Class 2). All other patients were event and angina free. CONCLUSION: This first clinical experience in patients with small vessel disease shows that the use of the R stent is safe and feasible with low rates of acute stent thrombosis.