Zülküf Karahan

Pulmonary hypertension in patients with essential thrombocythemia and reactive thrombocytosis

Increased incidence of pulmonary hypertension (PH) has been reported in patients with chronic myeloproliferative disorders. The exact incidence of PH in essential thrombocythemia (ET) is unknown. Most of the reported literature consists of case reports or small studies. We designed this study to asses the incidence of PH in patients with ET and reactive thrombocytosis. Previously or newly diagnosed 46 patients with ET, and 40 patients with reactive thrombocytosis secondary to iron deficiency anemia were found to be eligible for this study. Diagnosis of PH was established via transthoracic echocardiography. PH was found in 22 (47.8%) out of 46 patients with ET. Seven patients with PH were newly diagnosed ET, 5 patients with PH were in low, and the other patients with PH were in intermediate or high risk category. We found statistically significant difference in terms of platelet counts between ET patients with PH and without PH (p = 0.027). None of the patients with reactive thrombocytosis had PH. In conclusion, PH appears to be common in patients with ET. Therefore, all patients with ET should be evaluated for PH. Larger and prospective studies are required to clarify the long-term impact of PH on the survival of these patients. Future studies are also needed to determine whether cytoreductive treatment and aspirin prevent the development of PH, and to determine the effects of cytoreductive treatments and aspirin on the prognosis of PH. The effect of PH on ET prognosis should also be determined in low risk ET patients.

Neutrophil/lymphocyte ratio is associated with right ventricular dysfunction in patients with acute inferior ST-segment elevation myocardial infarction

BACKGROUND Acute inferior ST-segment elevation myocardial infarction (STEMI) is associated with increased in-hospital morbidity and mortality particularly among patients with coexisting right ventricular (RV) involvement. High neutrophil to lymphocyte ratio (NLR) is an independent predictor of major adverse cardiac events and mortality in patients with myocardial infarction. This study evaluated the relationship between the NLR and RV dysfunction (RVD) in patients with inferior STEMI who underwent primary percutaneous coronary intervention (PCI). METHODS A total of 213 subjects with inferior STEMI were divided into two groups according to the presence of RVD. The groups were compared according to NLR and receiver operating characteristic (ROC) analysis was performed to access the predictability of NLR on having RVD. RESULTS The NLR was significantly higher in the group with RVD compared to that without RVD (p < 0.001). In ROC analysis, NLR > 3.5 predicted RVD with sensitivity of 83% and specificity of 55%. In a multivariate regression analysis, NLR remained an independent predictor of RVD (OR 1.55, 95% CI 1.285-1.750, p < 0.001). CONCLUSIONS NLR was an independent predictor of RVD in patients with inferior STEMI undergoing primary PCI.

Effect of Hematologic Parameters on Microvascular Reperfusion in Patients With ST-Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention.

Objectives: Despite the significant role of certain hematologic parameters in reperfusion injury, their relationship with microvascular reperfusion remains not well understood. Therefore, our objective was to evaluate the relationship between hematologic parameters at admission and microvascular reperfusion in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (primary PCI). Methods: A total of 213patients (mean age: 57.5 ± 11 years) with STEMI were included. Blood samples were obtained from all patients prior to primary PCI. Electrocardiographic recordings were made for the evaluation of ST-segment resolution (STR) before and after primary PCI. Angiographic assessment in the infarct-related artery was performed using the myocardial blush grade (MBG) and thrombolysis in myocardial infarction (TIMI) flow. Patients were categorized into 2 groups as those with impaired microvascular reperfusion (STR <70%, TIMI: 0-1, and MBG: 0-1) and those with normal microvascular reperfusion (STR >70%, TIMI: 2-3, and MBG: 2-3). Results: Of the overall study group, 139, 105, and 69 patients had an STR of <70%, MBG of 0-1, and TIMI of 0-1, respectively. Demographic parameters in both groups are shown in the tables. Patients with impaired microvascular reperfusion were found to have higher white blood cell (WBC) count, neutrophil count, lymphocyte count, and mean platelet volume (MPV). Neutrophil–lymphocyte ratio and platelet count were similar between the 2 groups. Correlation analysis showed a negative correlation between lymphocyte count and STR (r: −.195, P: .004), lymphocyte count and TIMI flow(r: −.09, P: .14), and lymphocyte count and MBG (r: −.211, P: .002). Conclusion: Our results suggest that higher WBC count and MPV at admission are independent predictors of impaired microvascular perfusion in patients with STEMI. On the other hand, a negative correlation was found between lymphocyte count and impaired microvascular perfusion. Specifically, elevated lymphocyte count seemed to indicate the presence of impaired microvascular reperfusion in patients with STEMI.

QRS duration: a novel marker of microvascular reperfusion as assessed by myocardial blush grade in ST elevation myocardial infarction patients undergoing a primary percutaneous intervention.

ObjectivesProlonged QRS duration is a predictor of poor prognosis in patients with coronary artery disease. The association between the duration of QRS and myocardial reperfusion is not very well understood. Our aim was to assess the relationship between the measurements of QRS duration and myocardial blush grade (MBG) in patients with ST elevation myocardial infarction (STEMI) who were treated with a primary percutaneous intervention. Patients and methodsA total of 213 patients (mean age: 57.5±11 years) with STEMI were included. ECG recordings were obtained for the evaluation of the QRS duration before and after primary percutaneous coronary intervention. Angiographic assessment in the infarct-related artery was performed using the MBG. Patients were categorized into two groups of those with impaired microvascular reperfusion (MBG: 0–1) and those with normal microvascular reperfusion (MBG: 2–3). ResultsOverall, 105 and 108 patients had an MBG of 0–1 or 2–3, respectively. There is no significant difference between patient’s characteristics. Despite the absence of a difference between two groups in terms of the QRS duration at presentation (P: 0.57), patients with impaired microvascular reperfusion were found to have longer QRS duration at immediately postprocedure (P: 0.003) and postprocedure 60 min time-points (P<0.001). Correlation analyses showed a positive correlation between pain-to-balloon time and QRS duration at postprocedure 60 min time-points (r: 0.137 and P: 0.04). ConclusionOur results suggest that longer QRS duration after angioplasty seemed to indicate the presence of impaired microvascular reperfusion in patients with STEMI.

Relation between Apolipoprotein E Gene Polymorphism and Severity of Coronary Artery Disease in Acute Myocardial Infarction.

Apolipoprotein E (ApoE) is a plasma protein and associated with cholesterol transport system. In several studies, the relationship between ApoE gene polymorphism and severity of coronary artery disease (CAD) has been shown. However, the relationship between ApoE gene polymorphism and severity of CAD in patients with acute myocardial infarction (MI) has not been well known. The aim of this study is to investigate the relation between ApoE polymorphism and severity of CAD in patients with acute MI by using the Gensini Score. In this study, 138 patients were admitted to cardiology clinic with diagnosis of acute MI, and angiographic assessment was performed using the Gensini Score. Blood samples were obtained from all patients in the first day. The patients with ApoE34 genotype had high Gensini scores. Besides, the patients with E4 allele carriers were associated with high Gensini score compared with the patients without E4 allele carriers (p:0,22). The patients with E4 allele carriers were associated with higher LDL cholesterol and total cholesterol compared with the patients without E4 allele carriers (p:0,001 and p:0,03, resp.). There were no statistically significant differences between ApoE genotypes and severity of CAD by using the Gensini Score. But, the patients with E4 allele carriers were associated with high lipid levels.

Association Between ACE Gene Polymorphism and QT Dispersion in Patients with Acute Myocardial Infarction

Background: Angiotensin converting enzyme (ACE) gene polymorphism is associated with high renin-angiotensin system causing myocardial fibrosis and ventricular repolarization abnormality. Based on these findings, this study was designed to determine the association between ACE gene insertion/deletion (I/D) polymorphism and QT dispersion after acute myocardial infarction (MI). Objective and Methods: The study included 108 patients with acute MI. Blood samples were obtained from all the patients for genomic DNA analysis. ECGs were recorded at baseline and at the end of a 6-month follow up. The OT dispersion was manually calculated. Results: The mean age of the patients was 57.5 ±9.9 years (ranging from 36 to 70). The patients with DD genotype showed longer QT dispersion than patients with II or DI genotype at the baseline, while at the end of the six-month follow up the patients with DI genotype showed longer QT dispersion than patients with DD or II genotypes. However, the magnitude of the QT dispersion prolongation was higher in patients carrying the ACE D allele than patients who were not carrying it, at baseline and at the end of six-month follow up (52.5 ±2.6 msn vs. 47.5±2.1 msn at baseline, 57±3.2 msn vs. 53±2.6 msn in months, P: 0.428 and P: 0.613, respectively). Conclusion: Carriers of the D allele of ACE gene I/D polymorphism may be associated with QT dispersion prolongation in patients with MI.An interaction of QT dispersion and ACE gene polymorphism may be associated with an elevation of serum type I-C terminal pro-collagen concentration, possibly leading to myocardial fibrosis, and increased action potential duration.

Very Unusual Case Report: Type RIII of Lipton's Classification

Single coronary artery is a very rare congenital anomaly in the general population. We presented a 51 year-old male with typical chest pain, and coronary angiogram showed a single trunk from the right coronary sinus.

The association between prolongation in QRS duration and presence of coronary collateral circulation in patients with acute myocardial infarction

Background It is known that QRS duration is related to prognosis in acute myocardial infarction. The relation between QRS duration and coronary collateral circulation is uncertain. In the present study, we aimed to determine the relation between QRS duration and coronary collateral circulation in patients admitted with acute myocardial infarction. Methods The present study was composed of 109 consecutive patients with acute myocardial infarction. All patients had total occlusion in the left anterior descending coronary artery. Electrocardiographic recordings on admission were obtained for the assessment of QRS duration. The Rentrop classification was used to define coronary collateral circulation on coronary angiography. Patients were divided into two groups as follows: Group 1 with poor coronary collateral circulation (Rentrop 0–1) and Group 2 with good coronary collateral circulation (Rentrop 2–3). Results Of all patients, 62 patients were included in group 1 and 47 patients in group 2, respectively. In the present study, patients in the group 1 had longer QRS duration than patients in the group 2 (p < 0.005). Additionally, we found that Rentrop grading had negative correlation with both QRS duration and white blood cell count (r: −0.28; p < 0.005 and r: −0.35; p < 0.001). Conclusion Our study showed that there was an inverse relationship between QRS duration on admission and presence of coronary collateral circulation in patients with acute myocardial infarction.

Response to the letter regarding the article "Neutrophil/lymphocyte ratio is associated with right ventricular dysfunction in patients with acute inferior ST-elevation myocardial infarction".

Thank you for the opportunity to reply to comments [1] related to our article “Neutrophil/ /lymphocyte ratio is associated with right ventricular dysfunction in patients with acute inferior ST-elevation myocardial infarction” [2]. We are very honored to gather feedback on our work. In acute phase, it was shown that the mortality was reduced following percutanous intervention or fibrinolytic therapy in patients with acute inferior ST elevation myocardial infarction (STEMI) involving right ventricle (RV) [3, 4]. However, deaths and right-sided heart failure due to RV myocardial infarction are very rare in long-term [5, 6]. Thus, we aimed to search short-term (in-hospital) effects of RV myocardial infarction on mortality via measuring neutrophil/lymphocyte ratio (NLR). Although there are several methods described to define RV dysfunction, such as catheterization, magnetic resonance imaging, echocardiography is the simplest and easiest to apply in acute setting. To define RV involvement, we preferred to use tricuspid annular plane systolic excursion (TAPSE) levels in accordance with the guidelines [7], since it is easily and quickly measured in acute inferior STEMI setting without significant interobserver difference. Additionally we confirmed RV involvement with RV fractional area change which is smaller in patients with RV dysfunction. Thus, considering TAPSE to define RV dysfunction is methodologically acceptable. It is known that NLR value and number of leukocyte subgroups can differ according to time and the type of the tubes used for blood sample. However, there was no significant time difference between the groups in respect to time of admission and timing of blood sample collection. Additionally, complete blood count parameters were measured by a hematology analyzer immediately after sampling. Thus, time effect on our results is not valid. Also, all blood samples were carried to hematology analyzer in identical standardized tubes. Exclusion criteria of our study included all clinical conditions which can possibly affect NLR, such as cancer, presence of active infection, chronic pulmonary disease, pulmonary hypertension, malignancy, end-stage liver disease, renal failure and past history of a systemic inflammatory process. Thus, the results can be attributed to acute myocardial infarction itself. It is known that dehydration can lead to a change in NLR but there is no clear-cut measure to show dehydration or overhydration. Still, inferior vena cava diameter can be used to reflect hydration status. In our study, all patients had inferior vena cava diameter of > 12 mm which is an indirect indicator for absence of dehydration [6]. Thus, we can conclude that our results are free of dehydration effect of NLR. Additionally, inferior vena cava plethora in patients with RV dysfunction was more pronounced than in patients without RV dysfunction and this finding also indirectly reflects the increased right atrial pressure due to RV dysfunction. Even though red cell distribution width (RDW) is an emerging parameter related to the inflammation, the clinical role of RDW in the evaluation of cardiovascular events has not been confirmed in randomized clinical trials. We didn not think that addition of RDW along with NLR would contribute to findings of our study, thus it was not included. According to our results, one can easily be aware of the fact that NLR values over 3.5 have significant clinical implication. This finding implied that RV involvement along with acute inferior STEMI induces higher level of inflammatory state including higher number of neutrophils and higher level of stress with more steroid production. Increased steroid level causes suppressed lymphocyte production in bone marrow. This pathophysiological mechanism implies that higher level RV involvement contributes to more significant NLR increase. In respect to other inflammatory markers, such as C-reactive protein, myeloperoxidase and CLINICAL CARDIOLOGY