Nazif Aygul

Comparison of myocardial performance index obtained either by conventional echocardiography or tissue Doppler echocardiography in healthy subjects and patients with heart failure

This study was planned to investigate the normal reference values of myocardial performance index (MPI) obtained by tissue Doppler echocardiography (TDE) and the agreement between MPI measured by TDE and conventional MPI measured by pulsed-wave Doppler (PWD) in healthy subjects and patients with heart failure (HF). Two hundred and three patients with HF and 190 healthy subjects were enrolled in this study. Isovolumic contraction and relaxation time (ICT and IRT) and ejection time (ET) were measured from mitral inflow and left ventricular (LV) outflow. Tissue Doppler echocardiography recordings were obtained at the septal, lateral, inferior, and anterior of the mitral annulus and same time intervals were measured. Myocardial performance index was calculated. The functional capacity of the patients with HF was determined according to New York Heart Association classification. TDE-MPI values were higher than conventional PWD-MPI values in both groups (53% ± 8% vs 48% ± 11%, P < 0.0001 in the healthy subjects; 84% ± 21% vs 72% ± 19%, P <0.0001 in the patients with HF). Moderate agreement was found between PWD-MPI and LV mean TDE-MPI in both groups. In identifying patients with moderately or severely decreased LV ejection fraction, TDE-MPI had higher cutoff values than conventional PWD-MPI, and TDE-MPI had higher specificity, sensitivity, negative predictive value, and diagnostic accuracy. In patients with HF, TDE-MPI had a stronger correlation with LV ejection fraction and functional capacity than did PWD-MPI. TDE-MPI is an alternative to conventional PWD-MPI in assessment of cardiac function. However, the higher MPI cutoff points should be considered when this method is used for the evaluation of cardiac function.

Value of lead aVR in predicting acute occlusion of proximal left anterior descending coronary artery and in-hospital outcome in ST-elevation myocardial infarction: an electrocardiographic predictor of poor prognosis

BACKGROUND We aimed to investigate the value of ST elevation in lead aVR (ST upward arrow aVR) in predicting the left anterior descending coronary artery (LAD) occlusion site proximal to first septal perforator (S(1)) and its effect on in-hospital outcome in ST-elevation myocardial infarction (STEMI). METHODS The study included 950 patients with STEMI. Patients were divided into 2 groups as aVR(+) and aVR(-) according to the presence of an ST upward arrow aVR of 0.5 mm or greater. RESULTS ST elevation in lead aVR was seen in 155 (16%) patients, and LAD occlusion proximal to S(1) was detected in 52% of patients in the aVR(+) group and in 9% of patients in the aVR(-) group. aVR positivity was associated with higher heart rate, lower systolic blood pressure and ejection fraction, and worse Killip class at the hospital admission. In-hospital mortality was 19% in the aVR(+) group and 5% in the aVR(-) group. aVR positivity was an independent predictor of in-hospital death. CONCLUSION This study revealed that ST upward arrow aVR was not only a good indicator of LAD occlusion proximal to S(1) but also a source of valuable information about in-hospital outcome in patients with STEMI.

Short Communication: Assessment of exercise stress testing with artificial neural network in determining coronary artery disease and predicting lesion localization

The aim of this study is to show the artificial neural network (ANN) on determination of coronary artery disease existence and localization of lesion based upon exercise stress testing (EST) data. EST and coronary angiography were performed on 330 patients. The data studied acquiring 27 verifying features was normalized employing z-score method. To select training and test data, 10-fold cross-validation methods were involved and multi-layered perceptron neural network was employed for the classification. The interpretation of EST using ANN proved 91%, 73% and 65% diagnostic accuracy for the left main coronary (LMCA), left anterior descending and left circumflex coronary arteries, respectively. Besides, 69% for the right coronary artery is also predicted. For the LMCA, a 94% negative predictive value (NPV) was obtained. This high percentage of NPV encourages the elimination of LMCA lesions. Some knowledge can also be obtained about lesion localization, besides diagnosing of coronary artery disease by the assessment of EST via ANN.

Association of Fragmented QRS Complex with Myocardial Reperfusion in Acute ST‐Elevated Myocardial Infarction

In this study, we aimed to evaluate the relationship between TIMI myocardial perfusion (TMP) grade, as an indicator of myocardial reperfusion, and fragmented QRS (fQRS) in standard 12‐lead electrocardiogram. Also, we evaluate fQRS is an additional indicator of myocardial reperfusion. One hundred patients admitted with first STEMI to Coronary Intensive Care Unit and who were used thrombolytic therapy was included in this retrospective study. Standard 12‐lead electrocardiogram records of patients simultaneous with coronary angiography (second day) were assessed and analysed for the presence of fQRS. Also, coronary angiography images were analyzed to identify the infarct related artery, TIMI grade of infarct related artery and TMP grade of infarct related artery. The patients with fQRS demonstrated a significantly lower TMP grade, TIMI grade and ejection fraction compared with the non‐fQRS patients (P = 0.004, P = 0.003, P = 0.02 respectively). The patients with inadequate myocardial reperfusion demonstrated a significantly higher fQRS compared with the adequate myocardial reperfusion patients. (56.9% versus 23.5%, P = 0.002 respectively). On correlation analysis, there was a significant negative correlation between fQRS and left ventricular ejection fraction (r = −232, P = 0.02) TMP grade and adequate myocardial reperfusion (TMP 3) showed significant negative correlation with fQRS (r = −0.370, P = 0.000; r = −0.318, P = 0.001 respectively). Presence of fragmented QRS in STEMI patients was associated with inadequate myocardial reperfusion and it can be used as a simple, noninvasive parameter to evaluate myocardial reperfusion.

Comparison of increased aspirin dose versus combined aspirin plus clopidogrel therapy in patients with diabetes mellitus and coronary heart disease and impaired antiplatelet response to low-dose aspirin.

The effects of therapy with aspirin 300 mg/day and with combined aspirin 100 mg/day plus clopidogrel 75 mg/day on platelet function were compared in patients with diabetes mellitus and coronary artery disease and impaired antiplatelet responses to aspirin 100 mg/day. The study population consisted of 151 outpatients with type II diabetes mellitus and coronary artery disease who were taking aspirin 100 mg/day. Of the 151 patients, a subgroup of subjects with impaired aspirin response were selected on the basis of the results of platelet aggregometry. Nonresponsiveness to aspirin was defined as mean aggregation > or =69% with 3 micromol/L adenosine diphosphate and mean aggregation > or =70% with 2 micromol/L collagen. Aspirin semiresponders were defined as meeting 1 but not both of these criteria. Nonresponders and semiresponders were randomized equally to aspirin 300 mg/day and aspirin 100 mg/day plus clopidogrel 75 mg/day, and aggregation tests were repeated after 2 weeks. Sixty of the 151 patients with diabetes (40%) were found to respond to aspirin inadequately. Platelet aggregation induced by adenosine diphosphate and collagen decreased significantly after aspirin 300 mg/day or combined therapy. Combined treatment was found to have a stronger inhibitory effect on platelet aggregation induced by adenosine diphosphate than aspirin 300 mg/day (p = 0.002). Impaired aspirin response was resolved by increasing the aspirin dose or adding clopidogrel to aspirin (p <0.0001 for each). However, desired platelet inhibition was achieved in significantly more patients by combined treatment than by aspirin 300 mg/day (p <0.05). In conclusion, aspirin 100 mg/day does not inhibit platelet function adequately in a significant number of patients with diabetes mellitus and coronary artery disease. Increasing the aspirin dose to 300 mg/day or adding clopidogrel to aspirin can provide adequate platelet inhibition in a significant number of those patients with impaired responses to low-dose aspirin.

A case report of an unusual complication of Amanita phalloides poisoning: Development of cardiogenic shock and its successful treatment with intra-aortic balloon counterpulsation

Amanita phalloides is responsible for the majority of the fatalities caused by mushroom poisoning. It causes damage in liver, kidneys and rarely pancreas, causing encephalopathic coma, disseminated intravascular coagulation, hemorrhage and hypovolemic shock. However, its effect on cardiac functions has not been established yet. In this case report, we aimed to present a female patient poisoned by A. phalloides mushroom complicated with multi-organ failure and cardiogenic shock due to advanced left ventricular systolic dysfunction. This case report was the first to show a successful treatment of cardiogenic shock due to mushroom poisoning with intra-aortic balloon counterpulsation, whereas she did not respond to other therapies.

Relationship between systolic myocardial velocity obtained by tissue Doppler imaging and left ventricular ejection fraction: systolic myocardial velocity predicts the degree of left ventricular dysfunction in heart failure.

This study was planned to research the relationship between systolic myocardial velocity (Sm) obtained by tissue Doppler imaging (TDI) and left ventricular ejection fraction (LVEF) measured according to conventional Simpsons method in healthy subjects and patients with heart failure (HF). Two hundred eight patients with HF whose LVEF < 50% (mean age 59 ± 11 years) and 187 healthy subjects (mean age 57 ± 11 years) were enrolled in this study. LVEF was measured and TDI recordings were obtained at the septal, lateral, inferior, and anterior of the mitral annulus, and Sm was measured. LV mean Sm was calculated. In patients with HF, a significant correlation was detected between LVEF and Sm (r = 0.71, P < 0.0001), while no relationship was found between these parameters in healthy subjects (r = 0.16, not significant). The cutoff value of Sm < 8 cm/s for identifying patients with LVEF between 30% and 49% had a sensitivity of 86%, a specificity of 93%, and a negative predictive value of 92%, and the cutoff value of Sm < 6.0 cm/s for identifying patients with LVEF < 30% had a sensitivity of 92%, a specificity of 84%, and a negative predictive value of 97%. The time required to calculate the LVEF was significantly longer than that of LV mean Sm (327 ± 98 sec vs. 110 ± 29 sec, P < 0.0001), and LVEF had higher inter‐ and intraobserver variability. LV mean Sm obtained by TDI, a parameter that is reproducible, easily obtained, reliable, and practical, can be used to evaluate LV systolic function in patients with HF.

The Comparative Effects of Long-Term Carvedilol versus Bisoprolol Therapy on QT Dispersion in Patients with Chronic Heart Failure

Objectives: Carvedilol and bisoprolol reduce QT dispersion (QTD) in chronic heart failure (CHF). However, it is unclear whether there is a difference between the effects of the two drugs. The aim of the present study was to compare the long-term effects of carvedilol and bisoprolol on QTD in patients with CHF. Methods: Eighty-one patients with CHF with no previous β-blocker therapy were included in this prospective study. The patients were randomly allocated to carvedilol or bisoprolol therapy. Left ventricular ejection fraction (LVEF), heart rate (HR), QTD, and corrected QTD (QTcD) were calculated at baseline and at the 6th month of therapy. Results: In comparison to baseline values in both therapy groups, LVEF was significantly improved, and a statistically significant decrease was found in HR (carvedilol from 76 ± 12 to 65 ± 10 beats/min, p < 0.001; bisoprolol from 78 ± 13 to 65 ± 8 beats/min, p < 0.001) and QTcD (carvedilol from 85 ± 28 to 65 ± 22 ms, p < 0.001; bisoprolol from 83 ± 22 to 61 ± 20 ms, p < 0.001). In our study, carvedilol and bisoprolol were found to have similar effects on LVEF, HR, and QTcD. Conclusions: Carvedilol and bisoprolol decrease HR and QTcD in patients with CHF, and there is no meaningful difference between the two β-blockers as regards their effects on these parameters.

A Comparison of Artificial Intelligence Methods on Determining Coronary Artery Disease

The aim of this study is to show a comparison of multi-layered perceptron neural network (MLPNN) and support vector machine (SVM) on determination of coronary artery disease existence upon exercise stress testing (EST) data. EST and coronary angiography were performed on 480 patients with acquiring 23 verifying features from each. The robustness of the proposed methods is examined using classification accuracy, k-fold cross-validation method and Cohen’s kappa coefficient. The obtained classification accuracies are approximately 78% and 79% for MLPNN and SVM respectively. Both MLPNN and SVM methods are rather satisfactory than human-based method looking to Cohen’s kappa coefficients. Besides, SVM is slightly better than MLPNN when looking to the diagnostic accuracy, average of sensitivity and specificity, and also Cohen’s kappa coefficient.

Acute occlusion of the left main trunk presenting as ST-elevation acute coronary syndrome

Acute obstruction of the left main coronary artery (LMCA) is not frequently encountered. Electrocardiographic findings are important to early diagnosis in determining an acute obstruction of the LMCA, which requires immediate aggressive treatment, in this extremely unstable condition. However, there is no single typical electrocardiographic pattern representing acute occlusion of the LMCA. We describe a rare electrocardiographic finding that suggested ST-elevation acute coronary syndrome of the anterior zone due to left main trunk total occlusion.