Sinan Sahin

Effects of folic acid and N-acetylcysteine on plasma homocysteine levels and endothelial function in patients with coronary artery disease

Objective — Hyperhomocysteinaemia is related with premature coronary artery disease and adverse cardiac events in patients with coronary artery disease (CAD). It is assumed that hyperhomocysteinaemia causes endothelial dysfunction. In this study, the effect of folic acid and oral N-acetylcysteine (NAC) therapies on plasma homocysteine levels and endothelial function were evaluated in hyperhomocysteinaemic patients with CAD. Methods and results — 60 patients were randomized to either folic acid 5 mg or NAC 600 mg or placebo daily for eight weeks. Brachial artery endothelial functions were studied by using highresolution ultrasound and assessed by measuring endothelium-dependent dilation (EDD) and endothe-lium-independent dilation (NEDD). Folic acid and NAC therapies decreased plasma homocysteine (from 21.7 ± 8.7 jimol/l to 12.5 ± 2.5 jimol/l, P < 0.00l;from 20.9 ± 7.6 jimol/l to 15.6 ± 4.3 jimol/l, P = 0.03, respectively), and increased EDD (6.7 ± 6.1% P = 0.002,4.4 ± 2.6% P < 0.001, respectively) compared with placebo. There was no significant difference in improving EDD between the folic acid and the NAC group (6.7 ± 6.1%, 4.4 ± 2.6%, P = 0.168). In the univariate analyses there was an inverse correlation between the post-treatment homocysteine level and the percent change in EDD with folic acid therapy (r= -0.490, P = 0.028), but there was no correlation with the NAC therapy (r = 0.259, P = 0.333) Conclusions — In patients with hyperhomocysteinaemic CAD, folic acid and NAC lowered plasma homocysteine levels and improved endothelial function.The effects of both treatments in improvement of EDD were similar.

Effect of Hormone Replacement Therapy on Plasma Lipoproteins and Apolipoproteins, Endothelial Function and Myocardial Perfusion in Postmenopausal Women with Estrogen Receptor-α IVS1–397 C/C Genotype and Established Coronary Artery Disease

Effect of hormone replacement (HRT) therapy on plasma lipoproteins and apolipoproteins, endothelial function and myocardial perfusion in postmenopausal women with estrogen receptor-α (ER-α) IVS1–397 C/C genotype and established coronary artery disease. Background/Aims: Associations between various ER-α polymorphisms and clinical phenotypes have been studied, including lipid levels and coronary atherosclerosis. We studied 48 postmenopausal women to determine the effect of ER-α IVS1–397 polymorphism on the response to treatment with HRT. Methods: The study had a randomized, double-blind, placebo-controlled and crossover design. Patients were divided into two groups according to ER-α IVS1–397 polymorphism: CC genotype (n = 9); CT or TT genotype (n = 39). HRT was given continuously for 4 weeks, with 4-week washout periods between the treatment periods. Brachial artery Doppler and Tl-201 scintigraphy were performed at the end of each treatment period. Results: HRT lowered total cholesterol, LDL-c and Apo-B levels from baseline values (all p < 0.05) and to a similar degree in CC and CT/TT genotype patients. HRT increased estradiol, HDL-c and Apo A-1 levels relative to baseline values, but to a greater degree in CC patients (p = 0.04, 0.05 and 0.04 by ANOVA, respectively). HRT increased peak forearm blood flow, brachial artery diameter during reactive hyperemia and endothelium-dependent dilation in both groups, but to a greater degree in CC patients (p = 0.03, 0.03 and 0.04 by ANOVA, respectively). Summed stress and rest scores were also more markedly reduced in CC patients (p = 0.04 and 0.05, respectively). The increase in estradiol levels was strongly correlated with the improvement in endothelium-dependent dilation (r = 0.66, p < 0.01), which in turn showed negative correlation with summed stress (r = –0.62, p < 0.01) and rest scores (r = –0.52, p < 0.05) in the CC genotype group. Conclusion: These data suggest that the improvement in endothelium-dependent dilation and the reduction in perfusion abnormalities by increasing estradiol levels with HRT in postmenopausal women with coronary artery disease may differ with respect to different genotypes, the effect being more prominent in those patients with ER-α IVS1–397 CC genotype.

Acute myocardial infarction due to marijuana smoking in a young man: guilty should not be underestimated

Marijuana (cannabis) is a frequently used recreational drug that potentially imposes serious health problems. We present a case of acute myocardial infarction with chronic total occlusion of left main coronary artery due to marijuana smoking in a 27-year-old man, which was not previously reported. This case illustrate that marijuana abuse can lead to serious cardiovascular events.

Impact of Nonalcoholic Fatty Liver Disease on Myocardial Perfusion in Nondiabetic Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

Limited data exist on the role of nonalcoholic fatty liver disease (FLD) as a potential independent risk factor in the setting of acute coronary syndromes. The aim of this study was to evaluate the impact of FLD on myocardial perfusion and inhospital major adverse cardiac events (MACE) in the setting of ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). We examined 186 consecutive nondiabetic patients (mean age 58 ± 11 years and 76% men) who underwent primary PCI for STEMI by ultrasound within 72 hours of admission. FLD was graded according to a semiquantitative severity score as mild (score <3) or moderate to severe (score ≥3). Myocardial perfusion was determined by measuring myocardial blush grade (MBG) and ST-segment resolution (STR) analysis. Patients were divided into 2 groups according to FLD score (<3 or ≥3). There were no differences with regard to postprocedural Thrombolysis In Myocardial Infarction 3 flow grade between the 2 groups (89% vs 83%, p = 0.201). Patients with FLD score ≥3 were more likely to have absent myocardial perfusion (MBG 0/1, 37% vs 12%, p <0.0001), absent STR (27% vs 9%, p = 0.001), and higher inhospital MACE rate (31% vs 8%, p <0.0001). By multivariate analysis, FLD ≥3 score was found to be an independent predictor of absent MBG 0/1 (odds ratio [OR] 2.856, 95% confidence interval [CI] 1.214 to 6.225, p = 0.033), absent STR (OR 2.862, 95% CI 1.242 to 6.342, p = 0.031), and inhospital MACE (OR 2.454, 95% CI 1.072 to 4.872, p = 0.048). In conclusion, we found that despite similar high rates of Thrombolysis In Myocardial Infarction 3 after primary PCI, patients with FLD score ≥3 are more likely to have impaired myocardial perfusion which may contribute to adverse inhospital outcome.

A Late Sequela of the David Procedure: Left Main Coronary Artery Compression and Myocardial Infarction due to Pseudoaneurysm Formation

Valve-sparing root replacement (the David procedure) is a valuable alternative to conventional aortic root replacement with a composite graft, especially in patients whose aortic valve leaflets have not been altered. However, reintervention rates are higher than are those associated with composite graft implantation. In this report, we present the case of a patient who had undergone valve-sparing root replacement 2 years earlier and was admitted to our hospital with myocardial infarction and cardiogenic shock secondary to coronary ostial button dissection, aortic pseudoaneurysm formation, and severe left main coronary artery compression. To our knowledge, this case is exceedingly rare. Rather than attempt local reconstruction of the mouth of the pseudoaneurysm, we excised the lesion, the aortic valve, and the graft, and we successfully implanted a composite aortic graft with a mechanical aortic valve.

A hidden cause of hemoptysis: coronary artery-to-pulmonary parenchyma fistula.

A 60-year-old man presented with complaints of chronic hemoptysis present for many years and a six-month history of chest pain. Physical examination showed a grade II/VI continuous murmur at the left sternal border. Electrocardiography showed normal sinus rhythm and nonspecific ST-T changes in lateral leads. Echocardiography showed mild left ventricular hypertrophy. Exercise test was discontinued because of anginal symptoms and occurrence of lateral ST depression. Hemoptysis was observed a few times during hospitalization. Computed tomography of the thorax showed no abnormality to explain hemoptysis. Coronary angiography revealed a critical lesion in the left anterior descending artery and a large, tortuous right coronary artery with a fistulization tract originating from its proximal region and draining into the left lung parenchyma. The lesion in the left anterior descending artery was stented and percutaneous coil embolization of the fistula was performed in another session. Coronary angiography showed complete occlusion of the fistula and no residual shunting. In the six-month period after the procedure, the patient was free of symptoms of angina and hemoptysis.

A case of anomalous origin of circumflex artery from right sinus of valsalva recognized by three-dimensional transesophageal echocardiography and coronary computed tomography angiography

Anomalous origin of the circumflex coronary artery from the right sinus of Valsalva is the most common coronary anomaly. It is thought to be of no clinical relevance unless cardiac surgery is performed. We report a 53-year-old patient with aberrant circumflex coronary artery origin from the right aortic sinus of Valsalva which was first suspected from transthoracic 2D and transesophageal 3D echocardiographic views and confirmed by coronary CT angiography. The patient did not receive further diagnostic or therapeutic options. Therefore, we recommended medical therapy with optimal treatment of his cardiovascular risk factors together with regular clinical follow up.

Relation of presystolic wave on doppler examination to syntax score in patients with acute myocardial infarction

BackgroundThere are few reports demonstrating a relationship between presystolic wave (PSW) and left ventricular function. The aim of the present study was to investigate the associations between PSW and angiographic and echocardiographic characteristics of patients with acute myocardial infarction (AMI).MethodsWe studied 348 consecutive patients with AMI. Pulsed Doppler-echocardiography was used to assess the both diastolic functions and presence of PSW from left ventricular outflow tract. Patients were divided into two groups by the presence or absence of PSW. The Syntax score (SXscore) was calculated from baseline angiograms to assess the complexity and severity of coronary artery disease.ResultsThe overall prevalence of PSW was 51.1%. Compared to patients without PSW, patients with PSW presence had greater left ventricular ejection fraction (LVEF), greater septal a′ velocity, lower mitral E and septal e′ velocity and lower E/A and e′/a′ ratios. Also, median SXscore were significantly lower in the PSW presence group compared to PSW absence group [1 (6–14) vs. 12 (7–18), P = 0.013]. In addition, the number of patients with high-SXscore (> 16) was significantly lower in PSW presence group (24 vs. 42), (P = 0.006). In multiple logistic regression analysis, absence of PSW found independent predictor of high-SXscore (OR 2.297 95% CI 1.235–4.272; P = 0.009).ConclusionsWe found that the presence of PSW was related with higher LVEF, lower SXscore and lower stage diastolic dysfunction in patients with AMI. PSW may be used in prediction of the coronary artery disease complexity and it could help risk stratification in patients with AMI.

Diagonal earlobe crease associated with increased epicardial adipose tissue and carotid intima media thickness in subjects free of clinical cardiovascular disease

OBJECTIVE Atherosclerotic coronary artery disease is a leading cause of death, worldwide. Diagonal earlobe crease (DELC) has been suggested as a simple, noninvasive marker of cardiovascular disease. Although epicardial adipose tissue (EAT) thickness and carotid intima media thickness (CIMT) are closely related to atherosclerosis, the relation between EAT, CIMT, and DELC had yet to be studied. The present objective was to analyze this association. METHODS Subjects were apparently healthy individuals referred to the cardiology outpatient clinic. A total of 65 subjects with DELC and 65 age- and sex-matched controls without DELC were enrolled. EAT thickness and CIMT were measured and analyzed. RESULTS Epicardial adipose tissue thickness was significantly higher in the DELC group (0.57±0.12 vs. 0.35±0.05; p<0.0001). CIMT was also significantly higher in DELC group (0.85±0.16 vs. 0.60±0.15; p<0.0001). Correlation analysis showed that CIMT was significantly correlated with EAT thickness (r: 0.594; p<0.0001). Linear regression analysis showed that presence of DELC was independently associated with CIMT and EAT thickness. CONCLUSION A significant and independent association between the presence of DELC and increased CIMT and EAT thickness was presently determined, for the first time, in subjects free of clinical cardiovascular disease.

Anomalous Origin of the Left Anterior Descending Artery: A Report of Two Cases with Different Course of Target Vessels

Introduction: Pulmonary embolism results from thrombus migration into the pulmonary artery, with the most common cause being deep vein thrombosis. However, pulmonary embolism might not necessarily originate in the lower extremities, which necessitates specific diagnostic and therapeutic choices. Case Presentation: An 84-year-old man presented with acute pulmonary embolism, but with no sign of deep vein thrombosis or a thrombophilic state. He experienced complete resolution with medical therapy involving parenteral and oral anticoagulants. During the patients hospital stay, an abdominal CT scan revealed a 23 mm lumbar osteophyte compressing and displacing the inferior vena cava. The turbulent blood flow through the stenotic area might have caused a thrombus and the consequent pulmonary embolism. Conclusions: This is the first report of pulmonary embolism caused by inferior vena cava extrinsic compression due to an osteophyte. Such a diagnosis should be suspected if the patient lacks deep vein thrombosisandhypercoagulative states. Acutepulmonary embolism could be a rare consequence of osteoarthritis in the spine, although correct assessment is crucial to initiating lifelong oral anticoagulant therapy following the first episode of pulmonary embolism. Indeed, spinal surgery is generally avoided due to the high risks and the fact that extrinsic compression of the inferior vena cava cannot be radically resolved.