Veli Gokhan Cin

Slow coronary flow may be a sign of diffuse atherosclerosis. Contribution of FFR and IVUS.

Objective. — Slow coronary flow (SCF) is a phenomenon characterized by delayed opacification of coronary arteries in the absence of epicardial occlusive disease, in which many aetiological factors such as microvascular and endothelial dysfunction, and small vessel disease have been implicated. We aimed to investigate the epicardial resistance in relation with SCF by using fractional flow reserve (FFR) and intravascular ultrasound (IVUS). Both have been combined to disclose the related epicardial flow resistance and the arterial anatomy. Methods and results. — Coronary pressure and FFR measurement were performed in 19 (8 (42.1%) men, 11 (57.9%) women; age = 55.9 ± 9.4 years) patients with SCF. All patients underwent subsequent IVUS investigation at the same setting. As compared with expected normal values, FFR values were significantly lower (1.0 vs. 0.83 ± 0.13, p < 0.0001). In patients with SCF, a strong negative correlation was seen between TIMI frame count and FFR (r = –0.551, p < 0.05). Upon IVUS investigation, the common finding was longitudinally extended massive calcification throughout the epicardial arteries and increased intimal thickness (0.59 ± 0.18mm). A negative correlation between intimal thickness and FFR was determined (r = –467, p < 0.05). Conclusion. — We have demonstrated the decreased FFR in the patients with SCF. Decreased FFR levels have been attributed to increased resistance in the epicardial coronary arteries due to diffuse atherosclerotic disease which has been demonstrated by IVUS.

A comparison of 1-month and 6-month clopidogrel therapy on clinical and angiographic outcome after stent implantation

In this study, we aimed to disclose the net effect of long-term (6-month) clopidogrel treatment as compared to that of short-term (1-month) treatment in the poststenting period. A total of 278 patients with successful stent implantation were involved in the study. After preloading with 300 mg of clopidogrel orally (p.o.) 24 h prior to the procedure, randomly selected patients were given either 75 mg p.o. for 1 month (group A) or 75 mg p.o. for 6 months (group B). The patients were followed up clinically and underwent control angiography at 6 months regardless of their clinical status to delineate the coronary anatomy and assess quantitative computer-assisted (QCA) analysis. In 140 (50.4%) patients (group A), 244 (50.6%) stents were used to treat 237 coronary lesions, and in 138 patients (group B), 238 (49.4%) stents were used to treat 238 coronary lesions. There was no difference between the groups with respect to any of the clinical characteristics, intracoronary thrombus, antiaggregant therapy, the type of lesion, vessel score index, and baseline QCA parameters. In 62 patients binary in-stent restenosis (ISR) was determined with no statistical difference between the groups (group A: 20.7% vs group B: 23.9%, P = not significance). There was also no difference between the two groups at 6 months regarding QCA parameters. Thirty-seven of the 62 patients with restenosis have developed major adverse coronary events such as death, myocardial infarction, and target vessel revascularization (group A: 12.9% vs group B: 13.8%, P = not significant). In patients with chronic coronary syndrome, in the poststenting period, 6-month clopidogrel use as an adjunct to aspirin has shown no benefit over 1 month use with respect to clinical outcome and angiographic outcome, such as restenosis rate, follow-up, minimal luminal diameter, late loss, lost index, and net gain.

Usefulness of admission hematologic parameters as diagnostic tools in acute pulmonary embolism

The purpose of this study was to determine the role of red cell distribution width (RDW), neutrophil–lymphocyte ratio (NLR), and platelet–lymphocyte ratio (PLR) in the diagnostic phase of acute pulmonary embolism (PE). We screened 248 consecutive patients who were admitted to the emergency service with PE foremost in the differential diagnosis. Based on spiral computed chest tomography, the patients were divided into two groups. There were 112 confirmed cases of acute PE and 138 patients without PE. Blood samples were obtained within 2 hours of presentation and before starting any medication. There were no significant differences between the PE and the non‐PE groups with respect to sex, age, frequency of disease, serum creatinine, sodium, and potassium (p > 0.05 for all). NLR, RDW, and PLR were higher in patients with PE than those without PE. High‐sensitivity C‐reactive protein, d‐dimer, and troponin levels were also higher in patients with PE. RDW values were positively correlated with troponin levels (r = 0.147, p = 0.021). There were no correlations between RDW and NLR, PLR, or d‐dimer. NLR had a highly positive correlation with PLR (r = 0.488, p < 0.001). In multivariate logistic regression analysis, troponin I, d‐dimer, high‐sensitivity C‐reactive protein, and RDW were found to be independent predictors of PE [odds ratio (95% confidence interval) respectively: 5.208 (2.534–10.704), 1.242 (1.094–1.409), 1.005 (1.000–1.010), 1.175 (1.052–1.312)]. In receiver operating characteristic analysis of the patients in the study, RDW >18.9 predicted acute PE with a sensitivity of 20.7% and a specificity of 93.4%. In conclusion, RDW can be considered useful as a diagnostic measure for patients with suspected acute PE.

NT-Pro-BNP levels and their response to exercise in patients with slow coronary flow.

BACKGROUND Natriuretic peptides are released by the heart in response to wall stress. OBJECTIVE The NT-Pro-BNP concentrations in slow coronary flow (SCF) patients were assessed before and after the exercise test and compared with the values of healthy controls. METHODS The study population was 34 patients with SCF [22 males (64.7%), aged 51.0 ± 6.2 years], and 34 normal subjects with normal coronary arteries [21 males (61.8%), aged 53.2 ± 6.6 years]. Coronary flow rates of all patients and control subjects were documented as Thrombolysis in Myocardial Infarction (TIMI) frame count. Blood samples were drawn at rest and after the exercise testing. RESULTS The baseline NT-Pro-BNP concentrations of the SCF patients were higher than those of the control subjects (NT-Pro-BNP: 49.7 ± 14.2 pg/mL vs. 25.3 ± 4.6 pg/mL p<0.0001, respectively), and this difference increased after exercise test between the groups (NT-Pro-BNP: 69.5 ± 18.6 pg/mL vs. 30.9 ± 6.4 pg/mL p<0.0001). In SCF group after exercise, NT-Pro-BNP concentration in 15 patients with angina was higher than those without angina (76.8 ± 17.8 pg/mL vs. 63.8 ± 17.5 pg/mL p=0.041). NT-Pro-BNP concentration in 11 patients with ST depression was also higher than those without ST depression (82.4 ± 17.3 pg/mL vs. 63.3 ± 16.1 pg/mL p=0.004). Median post-exercise increases in NT-Pro-BNP (Δ NT-Pro-BNP) were higher in the SCF group than in the control group (Δ NT-Pro-BNP: 19.8 ± 7.7 pg/mL vs. 5.7 ± 4.5 pg/mL p<0.0001). CONCLUSION The results of this study suggest that there may be an important pathophysiologic link between the severity of SCF (microvascular or epicardial coronary artery dysfunction) and the level of circulating NT-Pro-BNP in SCF patients.

Impact of invasive strategy for the management of patients with cardiogenic shock after acute myocardial infarction

ObjectiveThis study evaluates the influence of early revascularization (with percutaneous transluminal coronary angioplasty (PTCA) and coronary surgery) on short- and long-term survival in patients with cardiogenic shock complicating acute myocardial infarction (AMI). Methods and resultsIn-hospital and 6-month survival were retrospectively determined on day 193 (65–270, median ±25th and 75th percentiles) in 87 patients who either underwent early invasive reperfusion (group A, n=60) or those who were treated conservatively (group B, n=27). In-hospital mortality was 37% in group A and 56% in group B (P=0.192). Six-month mortality was statistically lower in group A than in group B (30 patients (50%) compared with 25 patients (93%), P=0.005). Being a woman and older age were found to be factors increasing mortality. Lower mortality in the long term was strongly associated with revascularization (odds ratio=0.08, 95% confidence interval=1.54–109). PTCA was found to be an independent predictor of long-term survival (odds ratio= 0.22, 95% confidence interval=0.049–1.00, P=0.050), by multiple logistic regression. ConclusionsIn conclusion, this study suggests that early revascularization improves long-term survival of patients with cardiogenic shock complicating AMI, even after adjustment for baseline differences between patients who underwent early revascularization and those who did not.