Obstructive Sleep Apnea and Cardiovascular Disease: Where Do We Stand?

Obstructive sleep apnea is common in adults with cardiovascular disease. Accumulating evidence suggests an association between obstructive sleep apnea and cardiovascular disease independent of the traditionally recognized cardiovascular disease risk factors. Observational studies indicate that obstructive sleep apnea is a risk factor for development of cardiovascular disease and that alleviation of obstructive events with positive airway pressure may improve cardiovascular disease outcomes. However, recent randomized controlled trials have not supported the beneficial effect of positive airway pressure in cardiac populations with concomitant obstructive sleep apnea. Some evidence suggests that the relationship between obstructive sleep apnea and traditionally recognized cardiovascular disease risk factors is bidirectional, suggesting that patients with cardiovascular disease may also develop obstructive sleep apnea and that efficient treatment of cardiovascular disease may improve obstructive sleep apnea. Recent data also indicate that the apnea-hypopnea index, which is commonly used as a diagnostic measure of obstructive sleep apnea severity, has limited value as a prognostic measure for cardiovascular disease outcomes. Novel markers of obstructive sleep apnea-associated hypoxic burden and cardiac autonomic response seem to be strong predictors of adverse cardiovascular disease outcomes and response to treatment of obstructive sleep apnea. This narrative review and position paper from the Turkish Collaboration of Sleep Apnea Cardiovascular Trialists aims to update the current evidence about the relationship between obstructive sleep apnea and cardiovascular disease and, consequently, raise awareness for health professionals who deal with cardiovascular and respiratory diseases to improve the ability to direct resources at patients most likely to benefit from treatment of obstructive sleep apnea and optimize treatment of the coexisting cardiovascular diseases. Moreover, the Turkish Collaboration of Sleep Apnea Cardiovascular Trialists aims to contribute to strengthening the efforts of the International Collaboration of Sleep Apnea Cardiovascular Trialists in this context.

The value of NT-pro-brain natriuretic peptide and left ventricular ejection fraction for prediction of premature ventricular complexes burden

OBJECTIVE

We aimed to investigate the relation of NT-pro BNP level and left ventricular ejection fraction with premature ventricular complex burden.

PATIENTS AND METHODS

A total of 94 patients with PVC burden > 5% (age 45.9+12.9 years, 53 males, 41 females) were included in the study. The primary outcome was PVC burden % and main prognostic factors were LVEF% and NT-Pro BNP level. Gender, age, DM, HTN, presence of symptoms, symptom duration and heart rate were used as adjustment predictor variables. We created four different linear multivariable models to compare performance measures of prognostic factors: Model-1 has gender, age, DM, HTN, symptoms and heart rate, while LVEF has been added in addition to model-1 in model-2. Model-3 included NT-Pro-BNP alongside model-1 variables, while model-4 included both LVEF and NT-Pro-BNP variables in addition to model-1 variables. Accordingly, we compare the performance (R2, likelihood ratio X2) of models.

RESULTS

The median PVC burden was 18% (IQR; 11-27). When model-1 consisting of gender, age, DM, HTN, presence of symptoms, symptomS duration and heart rate and model-2 consisting of LVEF in addition to variables of model-1 were compared, it was observed that both LRX2 and R2 values improved (likelihood ratio test p-value=0.013). Model-1 compared with model-3 which consisting of NT-pro BNP in addition to variables of model-1, and it was observed that both LRX2 and R2 values improved (likelihood ratio test p-value=0.008). However, when compared to model-1, the most significant improvement was observed in both LRX2 and R2 values in model-4 consisting of model-1 plus NT-Pro-BNP and LVEF (likelihood ratio test p-value <0.001).

CONCLUSIONS

We determined that NT-pro-BNP levels and LVEF could predict PVC burden in patients. Higher levels of NT-pro-BNP and lower LVEF values were associated with increased PVC burden.

Evaluation of the effect of bun/albumin ratio on in-hospital mortality in hypertensive COVID-19 patients

OBJECTIVE

The impact of COVID-19 infection still continues all over the world and is an important cause of mortality. The mortality rate due to infection varies between 1-5%. The mortality rate is higher in those with cardiovascular risk factors, especially in cases with hypertension. Some studies have shown that blood urea nitrogen (BUN) and albumin levels are associated with worse prognosis in patients with COVID-19. In our study, we aimed to investigate whether the BUN/albumin (BAR) ratio has an effect on in-hospital mortality in hypertensive COVID-19 patients.

PATIENTS AND METHODS

A total of 800 hypertensive COVID-19 patients, (618 of whom were alive and 182 died) were included in our study. Patients with a history of heart failure, malignancy, acute coronary syndrome, and myocarditis were excluded.

RESULTS

The median age of the study population was 69 (60-77 IQR) years, and 305 (38%) of these patients were men. There was no statistically significant difference between the patients who died during follow-up and cases that remained alive in terms of comorbidities except chronic obstructive pulmonary disease (COPD) which was significantly lower in surviving group (p=0.014). Multivariable logistic regression analysis revealed that age [OR: 1.04, CI (1.01-1.06); p=0.002], male gender [OR: 1.85, CI (1.13-3.02); p=0.010], lymphocyte count [OR: 0.63, CI (0.40-0.98); p=0.038], SaO2 [OR: 0.82, CI (0.79-0.85); p<0.001] and BAR level [OR: 1.09, CI (1.04-1.16); p=0.001] were independent predictors of in-hospital mortality. ROC analysis yielded that BAR is a better predictor of in-hospital mortality compared to albumin and BUN alone.

CONCLUSIONS

BUN, albumin, and BAR levels were found to be reliable predictors of in-hospital mortality in COVID-19 patients, and BAR was also found to be a more reliable predictor than BUN and albumin levels. Hypertension is one of the major risk factors for morbidity and mortality in COVID-19 and, BAR presents additional prognostic data in hypertensive COVID-19 patients that may direct physicians for treatment intensification.

Improved health-related quality of life after cardioneuroablation in patients with vasovagal syncope

BACKGROUND

As the most common cause of syncope, vasovagal syncope (VVS) is mediated by parasympathetic overactivity and/or sympathetic withdrawal. Although catheter ablation of ganglionated plexi or cardioneuroablation has been used to treat VVS, its role in quality of life (QoL) has not been formally evaluated. The aim of this study was to demonstrate if this novel treatment results in improvement QoL of patients with VVS.

METHODS

Twenty-seven consecutive patients (age: 34 ± 14 years, 51.8% male) with dominant cardioinhibitory type VVS were prospectively enrolled in the study. After confirmation of > 3 s asystole on head-up tilt testing (HUT), all patients underwent cardioneuroablation. ECGs were obtained prior to procedure and at 12-month follow-up visit. HUTs were repeated 1 month after cardioneuroablation procedures. QoL was assessed with the use of SF-36, EQ-5D, and EQ VAS questionnaires.

RESULTS

ECG, HUT, and QoL data were available in all patients. At 12-month follow-up, heart rate on rest ECG significantly increased (from 74 ± 15 to 84 ± 14 bpm, p = 0.003). Repeated HUTs were negative in 23 (85.1%) patients. All of 27 patients remained free of syncope. QoL assessed by SF-36 score significantly improved in postprocedural follow-up (92 ± 9 and 96 ± 11, p = 0.016). Similarly, significant improvements in mobility, self-care, and usual activity domains of EQ-5D were observed (mean scores of 3.0 ± 1.5 and 2.1 ± 1.3, p < 0.001; 1.3 ± 0.9 and 1.2 ± 0.6, p = 0.041; 1.7 ± 1.0 and 1.4 ± 0.8 respectively). EQ-VAS score also improved significantly (39 ± 24 to 77 ± 18, p < 0.001).

CONCLUSION

Our findings suggest that cardioneuroablation may be associated with intermediate term improvement in QoL in patients with VVS.

Evaluation of cardiomyopathy with two-dimensional speckle tracking echocardiography in limb-girdle muscular dystrophy type 2A and 2B

PURPOSE

Cardiac involvement in limb-girdle muscular dystrophy (LGMD)2A and LGMD2B, the most common subgroups of LGMD, is controversial. Our study aims to determine whether myocardial dysfunction develops in LGMD2A and LGMD2B patients.

METHODS

The study included 16 LGMD2A, 12 LGMD2B patients, and 48 healthy individuals. Comparisons included demographic, clinical, and laboratory parameters of LGMD2A and LGMD2B subgroups and traditional echocardiography and two-dimensional speckle tracking echocardiography (2D-STE) parameters with the normal population.

RESULTS

The median age was 33 (22-39 interquartile range [IQR]) in the LGMD2A group, 33 (27-38 IQR) in the LGMD2B group, and 28 (25-35 IQR) in the control group. The left ventricular (LV) ejection fraction of both LGMD2A and LGMD2B groups was similar to the control group (p = 0.296 and p = 0.918). Apical 4-chamber longitudinal strain (LS), Apical 2-chamber LS, Apical 3-chamber LS, left ventricular global longitudinal strain (LVGLS)-mid-myocardial, LVGLS-endocardium, and LVGLS-epicardium were lower (less negative) in the LGMD2B group compared to the control group (p = 0.006, p = 0.001, p < 0.001, p < 0.001, p < 0.001, and p < 0.001, respectively).

CONCLUSION

LV 2D-STE parameters of LGMD2A patients were similar to the control group, while they decreased significantly (less negative) in LGMD2B patients, indicating that LV subclinical myocardial dysfunction may develop in LGMD2B patients.

Evaluation of Myocardial Strain by 2-Dimensional Speckle Tracking Echocardiography in Patients with Facioscapulohumeral Muscular Dystrophy

Background:

Facioscapulohumeral muscular dystrophy is one of the most common congenital muscle disorders. Whether facioscapulohumeral muscular dystrophy causes cardiac involvement is still controversial. Although electrocardiography and conventional echocardiography studies have been performed, there is no data on strain echocardiography in facioscapulohumeral muscular dystrophy. Our study aims to compare the myocardial strain parameters by 2-dimensional speckle tracking echocardiography in patients with facioscapulohumeral muscular dystrophy and the normal group.

Methods:

This prospective single-center study included 35 patients with facioscapulohumeral muscular dystrophy and 54 control patients. Demographic, clinical, and laboratory parameters of both groups were compared. In addition to conventional echocardiography images, myocardial strain parameters were performed using 2-dimensional speckle tracking echocardiography.

Results:

The median age of the study population was 25 (19-35 IQR) and 51 (57.3%) of them were male. Left ventricle-global circumferential strain was significantly lower in the facioscapulohumeral muscular dystrophy group than in the normal group [−20.3 (−22.0; −19.0) vs. −21.6 (−22.5; −20.0), P = .020]. Two-dimensional speckle tracking echocardiography findings except left ventricle-global circumferential strain [for left ventricle-global longitudinal strain P = .259, for left ventricle-global radial strain P = .338, for right ventricle-global circumferential strain P = .250, and for right ventricle-free wall longitudinal strain P = .288] were similar in both groups.

Conclusions:

As a result of our study, there was no significant difference between 2-dimensional speckle tracking echocardiography parameters other than the left ventricle-global circumferential strain between facioscapulohumeral muscular dystrophy and normal groups.

Comparison of Fragmented Electrogram Based Strategy and High Frequency Stimulation for Detection of Ganglionated Plexi

Ganglionated plexus (GP) ablation is an emerging technique in patients with cardioinhibitory vasovagal syncope and vagally mediated atrial fibrillation. Localization of GPs can be impacted by the technique used. A reproducible methodology for GP detection is needed to account for individual variations during electrophysiologic study. In this article, we aim to compare and contrast high-frequency stimulation vs. a fragmented electrogram guided strategy for GP localization.

Procedural and short-term results of electroanatomic-mapping-guided ganglionated plexus ablation by first-time operators: A multicenter study

INTRODUCTION

Single-center observational studies have shown promising results with fragmented electrogram (FE)-guided ganglionated plexus (GP) ablation in patients with vagally mediated bradyarrhythmia (VMB). We aimed to compare the acute procedural characteristics during FE-guided GP ablation in patients with VMB performed by first-time operators and those of a single high-volume operator.

METHODS AND RESULTS

This international multicenter cohort study included data collected over 2 years from 16 cardiac hospitals. The primary operators were classified according to their prior GP ablation experience: a single high-volume operator who had performed > 50 GP ablation procedures (Group 1), and operators performing their first GP ablation cases (Group 2). Acute procedural characteristics and syncope recurrence were compared between groups. Forty-seven consecutive patients with VMB who underwent FE-guided GP ablation were enrolled, n = 31 in Group 1 and n = 16 in Group 2. The mean number of ablation points in each GP was comparable between groups. The ratio of positive vagal response during ablation on the left superior GP was higher in Group 1 (90.3% vs. 62.5%, p = .022). Ablation of the right superior GP increased heart rate acutely without any vagal response in 45 (95.7%) cases. The procedure time was longer in group 2 (83.4 ± 21 vs. 118.0 ± 21 min, respectively, p < .001). Over a mean follow-up duration of 8.0 ± 3 months (range 2-24 months), none of the patients suffered from syncope.

CONCLUSION

This multi-center pilot study shows for the first time the feasibility of FE-guided GP ablation across a large group of procedure-naïve operators.

The relationship between coronary slow-flow and frontal QRS-T angle

OBJECTIVE

It is known that increased frontal QRS-T angle, which is a new ventricular repolarization marker is associated with adverse cardiac outcomes. It has been observed that the coronary slow-flow (CSF) phenomenon can cause arrhythmias and sudden cardiac death. The aim of our study is to investigate the relationship between CSF in patients and the frontal QRS-T angle.

MATERIAL AND METHOD

A total of 200 patients, 97 of who had CSF and 103 with the normal coronary flow (NCF), were included in our study. The CSF group was divided into two groups; single-vessel CSF and multi-vessel CSF. The TIMI-frame count was calculated from the coronary angiography images of each patient. 12-lead electrocardiography (ECG) records were examined. The frontal QRS-T angle was obtained from the automated reports of the ECG device.

RESULTS

The mean age of the study population was 50.7 ± 9.5 and 102 (51%) of patients were female. The frontal QRS-T angle was significantly higher in patients with CSF compared to the NCF group [48(31-64) vs 37(25-46), p = 0.001]. A positive correlation was observed between the frontal QRS-T angle and TIMI-frame count in the correlation analysis performed separately for LAD, Cx, RCA patients with CSF (respectively; r = 0.340 and p < 0.001, r = 0.262 and p = 0.002, r = 0.247 and p = 0.003). The frontal QRS-T angle was higher in patients with multi-vessel CSF than in patients with single-vessel CSF [53.5(41.5-76.5) vs 43.0(23.5-60.5), p = 0.039].

CONCLUSION

There is a positive correlation between frontal QRS-T angle and TIMI-frame count. The frontal QRS-T angle is higher in patients with CSF. Also, frontal QRS-T angle was higher in the multi-vessel CSF group.

Myocardial strain assessment by 2D speckle-tracking echocardiography in patients with congenital myopathy

Background:

Congenital myopathies (CMs) are a group of rare genetic muscle disorders. Cardiac involvement can be seen in these patients. We aimed to evaluate the myocardial strain parameters by 2D speckle-tracking echocardiography (STE) in patients with CM.

Materials and Methods:

Twenty-four patients with CM whose diagnosis was confirmed by genetic analysis or muscle biopsy were included in the study, and 48 patients were involved as a control group. Left ventricular ejection fraction (LVEF%) was calculated by biplane Simpson method, and myocardial strain analysis was performed by 2D STE.

Results:

The median age of the study population was 26 (19–35 interquartile range [IQR]) and 43 (60%) were women. In the analysis performed after the exclusion of two patients with multiminicore disease (MMD) who developed heart failure, although mild, LVEF% (62 [60–65 IQR] vs. 64 [63–66 IQR], P = 0.008) and right ventricular global longitudinal strain (RVGLS) were significantly lower in the CM group (−21.8 [−19.7, −24.9 IQR] vs. −23.9 [−22.4, −25.6 IQR], P = 0.0017). Left ventricular global longitudinal strain (LVGLS) was observed similarly in both groups (−19.9 [−18.7, −20.7 IQR] vs. −20.5 [−19.3, −21.9 IQR], P = 0.069). LVEF% (33 and 46), LVGLS (−7.5 and −10.7), and RVGLS (−14.9 and −16.1) values were low in two siblings with MMD.

Conclusion:

Although LVEF% and RVGLS were significantly lower in the CM group, LVGLS was similar. The decrease in RVGLS and LVEF% was mild, and heart failure was not observed in any patient except MMD patients who were not included in the analysis.

The effect of favipiravir on QTc interval in patients hospitalized with coronavirus disease 2019

Background

The effect of favipiravir on the QTc interval during the treatment of Coronavirus Disease 2019 (COVID-19) patients is unclear. Thus, the current study objective was to evaluate any change in the QTc interval in patients who were hospitalized due to COVID-19 receiving favipiravir treatment.

Method

Patients hospitalized with COVID-19 were assessed in this single-center retrospective study. 189 patients, whose diagnosis was confirmed using real-time PCR, were included in the study. The patients were divided into three groups: those using hydroxychloroquine (Group 1, n = 66), hydroxychloroquine plus favipiravir (Group 2, n = 66), and favipiravir only (Group 3, n = 57). The QTc interval was measured before treatment (QTc-B) and 48 h after (i.e., the median) starting treatment (QTc-AT).

Results

The median age was 53 (39–66 IQR) and 97 (51%) of patients were female. The median QTc(Bazett)-change was 7 ms (p = 0.028) and 12 ms (p < 0.001) and in Group 1 and 2, respectively. In Group 3, the median QTc(Bazett)-change was observed as −3 ms and was not statistically significant (p = 0.247). In multivariable analysis, while there was a significant relationship between QTc-AT(Bazett) and hydroxychloroquine (β coefficient = 2687, 95%CI 2599–16,976, p = 0,008), there was no significant relationship with favipiravir (β coefficient = 0,180, 95% CI -6435-7724, p = 0,858). Similarly, there was a significant relationship between the QTc-AT interval calculated using the Fredericia formula and hydroxychloroquine (β coefficient = 2120, 95% CI 0,514–14,398, p = 0,035), but not with favipiravir (β coefficient = 0,111, 95% CI -6450- 7221, p = 0,911).

Conclusion

In the ECG recordings received in the following days after the treatment was started in COVID-19 patients, there was a significant prolongation in the QTc interval with hydroxychloroquine, but there was no significant change with favipiravir.

Catheter Ablation of Atrioventricular Block: From Diagnosis to Selection of Proper Treatment

A 39-year-old man presented with recurrent syncope. A 12-lead electrocardiogram and a 24-h Holter recording demonstrated atypical persistent Mobitz type I and high-degree atrioventricular block, respectively. The functional nature of the atrioventricular block was confirmed by atropine challenge, exercise testing, and electrophysiological study. The patient was successfully treated with a cardioneuroablation procedure. (Level of Difficulty: Intermediate.).

The Association of Fractional Pulse Pressure with Acute Kidney Injury in Patients Undergoing Coronary Intervention due to ST-Segment Elevated Myocardial Infarction

OBJECTIVE

Acute kidney injury (AKI), which is prevalent in ST-segment elevated myocardial infarction (STEMI) patients who have undergone primary percutaneous coronary intervention (PCI), is associated with poor cardiovascular outcomes. As high pulse pressure (PP) is associated with adverse cardiovascular events, the present study's aim was to evaluate the relationship between fractional PP (PPf) and AKI in patients with STEMI who underwent primary PCI.

SUBJECTS AND METHODS

All laboratory findings as well as echocardiographic and angiographic data of 1,170 consecutive STEMI patients were retrospectively screened. PPf was calculated from the pressures invasively measured after sheath insertion and before performing coronary angiography.

RESULTS

From 1,170 eligible STEMI patients (mean age 56 years, 18.2% female), AKI developed in 143 (12.2%) patients. The PPf and pulsatility index were significantly higher in patients with AKI than those without (0.53 ± 0.10 vs. 0.61 ± 0.10, p < 0.001, and 0.80 ± 0.03 vs. 0.82 ± 0.03, p < 0.001, respectively). PPf was also found to be associated with AKI in univariable (OR 2.183, 95% CI 1.823-2.614, p< 0.001) and multivariable (OR 1.874, 95% CI 1.513-2.322, p < 0.001) analysis. In-hospital mortality was higher in patients with AKI than those without.

CONCLUSION

Invasively measured PPf, which can be easily measured and has no additional cost in STEMI patients undergoing coronary intervention, is an independent predictor of AKI. In addition, PPf is superior to other blood pressure values and derivatives in AKI prediction.

The effect of idiopathic premature ventricular complexes on left ventricular ejection fraction

Aim

Current literature lacks a definitive threshold of idiopathic premature ventricular complex (PVC) burden for predicting cardiomyopathy (CMP). The main objective of the present study was to evaluate relationship between the PVC burden and left ventricular ejection fraction (LVEF).

Method

This multicenter, cross‐sectional study included 341 consecutive patients with more than 1,000 idiopathic PVC in 24 hr of Holter monitoring admitted to the cardiology clinics between January 2019 and May 2019 in the nineteen different centers. The primary outcome was the LVEF measured during the echocardiographic examination.

Result

Overall, the median age was 50 (38–60) and 139 (49.4%) were female. Percentage of median PVC burden was 9% (IQR: 4%–17.4%). Median LVEF was found 60% (55–65). We used proportional odds logistic regression method to examine the relationship between continuous LVEF and candidate predictors. Increase in PVC burden (%) (regression coefficient (RE) −0.644 and 95% CI −1.063, –0.225, p < .001), PVC QRS duration (RE‐0.191 and 95% CI −0.529, 0.148, p = .049), and age (RE‐0.249 and 95% CI −0.442, −0.056, p = .018) were associated with decrease in LVEF. This inverse relationship between the PVC burden and LVEF become more prominent when PVC burden was above 5%. A nomogram developed to estimate the individual risk for decrease in LVEF.

Conclusion

Our study showed that increase in PVC burden %, age, and PVC QRS duration were independently associated with decrease in LVEF in patients with idiopathic PVC. Also, inverse relationship between PVC burden and LVEF was observed in lower PVC burden than previously known.

Prolonged P wave peak time is associated with the severity of coronary artery disease in patients with non-ST segment elevation myocardial infarction

BACKGROUND

Multi-vessel coronary artery disease (CAD) is associated with worse outcome in non-ST segment elevation myocardial infarction (NSTEMI) patients. Depending on the severity of CAD, there may be prolongation of atrial depolarization time as a result of left ventricular dysfunction and atrial ischemia. Therefore, we aimed to study whether the severity of CAD can be predicted with the P wave peak time (PWPT) in the electrocardiography (ECG) obtained during the diagnosis in NSTEMI patients.

METHOD

A total of 162 patients were included. The coronary angiography records of all patients were analyzed and SYNTAX scores were calculated. Patients were divided into two groups, according to CAD severity. In addition to well-known P wave parameters, PWPT, defined as the time from the beginning of the P wave to its peak, was measured in the leads D_II and V₁.

RESULTS

The PWPTs in the leads D_II and V₁ were significantly longer in the group with severe CAD (71 ± 13 vs. 61 ± 12, p < 0.001, 63 ± 24 vs. 53 ± 18, p = 0.024, respectively). PWPT was found to be an independent predictor of severe CAD and the best cut-off value of PWPT in the lead D_II was 69.6 ms with sensitivity of 58.3% and specificity of 78.9%.

CONCLUSION

Our findings show that prolonged PWPT, which is a parameter easily obtainable from the ECG, is associated with severe CAD. Recognition of NSTEMI patients with severe CAD at the time of diagnosis before performing coronary angiography may be important for the planning of treatment.

Impact of right ventricular diastolic dysfunction on clinical outcomes in inferior STEMI

BACKGROUND

The aim of this study was to investigate the prognostic value of restrictive right ventricular filling pattern (RRVFP) in patients with the first acute inferior wall myocardial infarction (IWMI) complicated by right ventricular myocardial infarction (RVMI) undergoing primary percutaneous coronary intervention (p-PCI).

METHOD

A total of 152 patients with acute IWMI complicated by RVMI undergoing p‑PCI were divided into two groups according to the presence of RRVFP. RRVFP was defined as tricuspid diastolic early/late flow velocities (Et/At) > 2 and Et deceleration time (DT) < 120 ms.

RESULTS

There were 23 patients with RRVFP in the study cohort. At, DTt, isovolumetric relaxation time (IVRT), and tissue Doppler tricuspid annular late velocity (A't) were reduced significantly in patients with RRVFP than in those without RRVFP (At 19.6 ± 2.7 vs. 39.1 ± 7.4 cm/s, p < 0.001; DTt 106 ± 13 vs.156 ± 21 ms, p = 0.001; IVRT 59 ± 6.7 vs. 62 ± 7.4 ms, p = 0.01; A't 4.6 ± 1.1 vs. 8.6 ± 1.05, p = 0.001). Et/At ratios were higher in patients with RRVFP than in those without RRVFP (Et/At 2.20 ± 0.2 vs. 1.15 ± 0.37, p < 0.001). Et, tissue Doppler tricuspid annular early velocity (E't), E't/A't ratio, and Et/E't ratio were not significantly different between groups (Et 43.3 ± 5.4 vs. 40.7 ± 9.2 cm/s p = 0.18; E't 8.8 ± 1.4 vs. 9.5 ± 2.3, p = 0.15; E't/A't 1.08 ± 0.24 vs. 1.13 ± 0.30, p = 0.52; Et/E't ratio 5.0 ± 1.1 vs. 4.5 ± 1.5 p = 0.09). Presence of E't/A't > 2, short DTt, RRVFP, unsuccessful p‑PCI, and cardiogenic shock on admission were independent predictors of in-hospital mortality (p < 0.05) in multivariable logistic regression analysis.

CONCLUSION

Presence of RRVFP is associated with in-hospital mortality in patients presenting with their first IWMI complicated by RVMI.

Auditory changes in acromegaly

OBJECTIVE

The aim of this study is to determine the changes involving auditory system in cases with acromegaly.

MATERIALS AND METHODS

Otological examinations of 41 cases with acromegaly (uncontrolled n = 22, controlled n = 19) were compared with those of age and gender-matched 24 healthy subjects. Whereas the cases with acromegaly underwent examination with pure tone audiometry (PTA), speech audiometry for speech discrimination (SD), tympanometry, stapedius reflex evaluation and otoacoustic emission tests, the control group did only have otological examination and PTA. Additionally, previously performed paranasal sinus-computed tomography of all cases with acromegaly and control subjects were obtained to measure the length of internal acoustic canal (IAC).

RESULTS

PTA values were higher (p < 0.001 for right ears and p = 0.001 for left ears), and SD scores were (p = 0.002 for right ears and p = 0.002 for left ears) lower in acromegalic patients. IAC width in acromegaly group was narrower compared to that in control group (p = 0.03 for right ears and p = 0.02 for left ears). When only cases with acromegaly were taken into consideration, PTA values in left ears had positive correlation with growth hormone and insulin-like growth factor-1 levels (r = 0.4, p = 0.02 and r = 0.3, p = 0.03). Of all cases with acromegaly 13 (32%) had hearing loss in at least one ear, 7 (54%) had sensorineural type and 6 (46%) had conductive type hearing loss.

CONCLUSION

Acromegaly may cause certain changes in the auditory system in cases with acromegaly. The changes in the auditory system may be multifactorial causing both conductive and sensorioneural defects.

Relationship between fragmented QRS complexes in leads V4-V6 and left ventricular apical thrombus formation in patients presenting with first acute anterior myocardial infarction

OBJECTIVE

The present study was an investigation of the relationship between fragmented QRS (fQRS) and left ventricular apical thrombus (LVAT) in patients presenting with first acute anterior myocardial infarction (MI).

METHODS

Consecutive 148 patients (mean age: 60.1±10.1 years; male: 75.6%) with first acute anterior MI who underwent primary percutaneous coronary intervention (PCI) were included. Study population was divided into 2 groups based on presence of LVAT. fQRS was defined as presence of various RSR' patterns, which included additional R wave or notching of R wave or S wave, and presence of more than 1 R in 2 contiguous leads corresponding to major coronary artery territory on 12-lead electrocardiogram. Patients with bundle branch block were excluded from the study.

RESULTS

Of these, 32 (21.6%) had LVAT. Patients with LVAT had higher prevalence of fQRS (53.1% vs. 22.4%; p<0.001) and lower rate of successful PCI (75% vs. 94%; p=0.002) compared with patients without LVAT. More patients in LVAT group had left ventricular ejection fraction of <30% (87.5% vs 65.5%; p=0.010). Groups were similar with respect to other baseline characteristics (p>0.05 for all). Presence of fQRS was independent predictor of LVAT (odds ratio [OR], 2.795; 95% confidence interval [CI], 1.058-7.396) in multivariable logistic regression analysis.

CONCLUSION

Presence of fQRS in leads V4-V6 is independently associated with LVAT in patients presenting with first acute anterior MI.

[Mean platelet volume and the extent of coronary atherosclerosis in patients with stable coronary artery disease]

OBJECTIVES

The aim of this study was to assess the relationship between mean platelet volume (MPV) and the presence and extent of coronary artery disease (CAD) in patients who underwent coronary angiography for stable chest pain.

STUDY DESIGN

A total of 540 patients (350 male, 190 female; mean age: 59.6±11.4 years) were consecutively included in the study. The patients were divided into four groups according to the presence and extent of their CAD as follows: Group 1 - patients with no significant CAD, group 2 - one vessel disease, group 3 - two vessel diseases, and group 4 - three vessel disease. Also, the Gensini score of each coronary angiogram was calculated.

RESULTS

There were 159 patients in group 1, 169 in group 2, 110 in group 3, and 102 in group 4. As expected, we found significant differences among the groups regarding mean age and other coronary risk factors including gender, hypertension, diabetes mellitus, hyperlipidemia, smoking, and family history of ischemic heart disease. However, there were no significant differences among the groups regarding platelet counts and MPV values (8.5±0.1 fl, 8.5±1.2 fl, 8.6±0.9 fl and 8.6±0.9 fl, MPV values of groups 1-4, respectively). Although the Gensini score was found to be significantly correlated with age, plasma uric acid level, white blood cell count, hemoglobin level, fasting blood glucose, and high density lipoprotein level, no significant association was detected between MPV and Gensini score values.

CONCLUSION

This study is one of the largest studies assessing the relationship between MPV and the extent of coronary atherosclerosis in patients with stable CAD to date. However, we found no association between MPV and the presence and extent of coronary atherosclerosis.

Value of the neutrophil-to-lymphocyte ratio in predicting post-pericardiotomy syndrome after cardiac surgery

OBJECTIVE

Post-pericardiotomy syndrome (PPS) occurs in 10-40% of patients after cardiac surgery. PPS is considered an autoimmune phenomenon. The neutrophil-to-lymphocyte ratio (NLR) is a novel inflammatory marker that is associated with various cardiovascular diseases. Studies have reported that the NLR increases in certain autoimmune diseases. This study examined whether the NLR is helpful to predict the occurrence of PPS after elective on-pump coronary artery bypass graft (CABG) surgery.

PATIENTS AND METHODS

The records of patients who underwent elective first-time on-pump CABG were reviewed retrospectively. In total, 72 patients with PPS were included in the study, and 100 patients who did not develop PPS were included as the control group. Peripheral blood samples collected preoperatively and on postoperative day 1 were used to calculate the NLR.

RESULTS

No differences in preoperative white blood cell (WBC) count, neutrophil count, lymphocyte count, or NLR were observed between the patients with PPS and the control group. The WBC (p < 0.001) and neutrophil counts (p < 0.001) and NLR (p = 0.01) were significantly higher during the postoperative period in patients with PPS than in the control group. A receiver operating characteristic curve analysis showed that the postoperative NLR predicted PPS with 60% sensitivity and 59% specificity (area under the curve, 0.61; 95% confidence interval [CI], 0.51-0.70; p = 0.017), using a cut-off of 8.34. The postoperative WBC count (odds ratio [OR], 1.6; 95% CI, 1.36-2.03; p < 0.001) and NLR (OR, 3.3; 95% CI, 1.56-7.01; p = 0.002) were independently associated with PPS.

CONCLUSIONS

The postoperative NLR may be useful to predict the development of PPS in patients undergoing on-pump CABG.

Role of methylprednisolone in the prevention of postpericardiotomy syndrome after cardiac surgery

OBJECTIVE

Postpericardiotomy syndrome (PPS) occurs in 10-40% of patients after cardiac operations. Pericardial effusions and tamponade occurring > 7 days after surgery are usually related to PPS and remain an important cause of cardiac surgery-related morbidity and mortality; therefore, preventing PPS is important. Colchicine affords safe and efficacious protection against PPS and related complications. However, the roles of corticosteroids and nonsteroidal anti-inflammatory drugs in PPS prevention remains unclear. This study aimed to determine whether the intraoperative use of single-dose methylprednisolone can effectively prevent PPS.

PATIENTS AND METHODS

This retrospective study included 100 patients undergoing elective coronary artery bypass grafting (CABG) who received a single intraoperative dose of 1 mg/kg methylprednisolone. A further 100 patients undergoing CABG, who were not given methylprednisolone, comprised the control group. The presence and severity of pericardial effusion was determined by echocardiography, with chest X-ray used to assess pleural effusion.

RESULTS

PPS occurrence and pericardial effusion occurrence were significantly lower in patients who received methylprednisolone (p = 0.02 and p = 0.007 respectively). Although the differences were not statistically significant, pericardial and pleural effusions were more severe in the control group than in the methylprednisolone group. Logistic regression analysis demonstrated that methylprednisolone administration was independently associated with prevention of PPS (OR 0.8, 95% CI 0.25-0.91, p <  0.026).

CONCLUSIONS

Intraoperative, single-dose methylprednisolone may confer protection against PPS in patients undergoing CABG.

Relationship between thyroid function and carotid artery plaque ulceration

Carotid artery plaque ulceration (PU) is known to be associated with cerebrovascular events (CVE). Even within euthyroid ranges, thyroid function has been reported to be associated with carotid atherosclerosis. However, the relationship between thyroid function and carotid PU remains unclear. Our aim was to determine the relationship between thyroid function and PU in patients with internal carotid artery stenosis (ICS). Records of patients with CVE were retrospectively reviewed. A total of 250 consecutive patients with ICS who had computed tomography angiography (CTA) of the carotid arteries following hospitalization were included in the study. CTA was used for the evaluation of carotid artery plaque morphology and ulceration. Plaque morphology was classified as fatty, mixed or calcified. Patients were divided into two groups according to the presence or absence of PU. Subclinical hypothyroidism (SCH) and hypothyroidism were significantly more common in patients with PU (p < 0.001 and p = 0.003, respectively). Patients with PU had higher incidence of low-normal FT4 levels (p = 0.02). Compared with patients who had no PU, patients with PU had decreased FT4 levels and elevated TSH levels (p = 0.001 and p = 0.001, respectively). TSH level (OR 1.33, p = 0.001), SCH (OR 4.2, p = 0.001), hypothyroidism (OR 3.15, p = 0.037), fatty plaque (OR 2.16, p = 0.01) and calcified plaque (OR 0.19, p < 0.001) were independently associated with PU. Our results suggest that SCH and hypothyroidism could be a risk factor for PU and subsequent CVE. Thyroid functions may be useful for risk stratification of patients with ICS.

Woven right coronary artery: A rare coronary anomaly

Woven coronary artery is an extremely rare anomaly in which epicardial coronary arteries divided into thin tunnel-like channels. WCA is thought to be a benign condition, however, it was associated with myocardial infarction and ischemia in some case reports. We present a 61-year-old male patient with woven right coronary artery.

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.

Value of serial platelet indices measurements for the prediction of pulmonary embolism in patients with deep venous thrombosis

BACKGROUND

To date, no validated biomarkers with high sensitivity and specificity have been established for diagnosis of pulmonary embolism (PE) in patients with deep venous thrombosis (DVT). There is a need to develop simple and reliable noninvasive tests that can accurately identify patients with PE, even in small hospitals or clinics. The aim of this study was to investigate the value of mean platelet volume (MPV) and platelet distribution width (PDW) for predicting occurrence of PE in patients with DVT.

METHODS

Records of acute DVT patients were reviewed retrospectively. Group 1 consisted of 50 patients with acute DVT and group 2 consisted of 50 patients with acute DVT who developed PE during follow-up. The control group consisted of patients with uncomplicated primary varicose veins of the lower limbs. Venous peripheral blood samples for measurement of MPV, PDW, and platelet count were drawn on admission, before the treatment, and at the time of PE diagnosis.

RESULTS

MPV and PDW levels at the time of PE diagnosis were higher in group 2 than group 1 (P<0.001 and P=0.026, respectively). Receiver operating characteristics analysis revealed that a 5.2% increase in admission PDW during follow-up provided 70% sensitivity and 82% specificity (area under the curve, 0.80), and a 6.6% increase in admission MPV during follow-up provided 74% sensitivity and 83% specificity (area under the curve, 0.84) for prediction of PE occurrence in patients with DVT. PDW and MPV levels at the time of PE diagnosis were found to be independent risk factors for the occurrence of PE in patients with DVT.

CONCLUSION

Serial measurements of MPV and PDW, and percent change in MPV and PDW appears to be a useful marker for predicting occurrence of acute PE in patients with a first episode of acute proximal DVT.

The relationship between eosinophilia and slow coronary flow

Aim

The pathophysiology of slow coronary flow (SCF) involves atherosclerosis, small vessel dysfunction, platelet function disorders, and inflammation. It has been known that eosinophils also play a significant role in inflammation, vasoconstriction, thrombosis, and endothelial dysfunction. We propose to evaluate the relationship between eosinophilia and SCF.

Methods

All patients who underwent coronary angiography between January 2011 and December 2013 were screened retrospectively. Of 6,832 patients, 102 patients with SCF (66 males, mean age 52.2±11.7 years) and 77 control subjects with normal coronary angiography (50 males, mean age 50.7±8.1 years) were detected. Baseline characteristics, hematological test results, and biochemical test results were obtained from the hospital database.

Results

Baseline characteristics of the study groups were comparable between groups. There was no significant difference between groups regarding leukocyte count, paletelet count, and mean platelet volume. However, patients with SCF had a higher eosinophil count than the controls (0.24±0.17×10³/μL vs 0.16±0.15×10³/μL, P=0.002). In addition, eosinophil count was found to be correlated with thrombolysis in myocardial infarction (TIMI) frame count in the SCF group (r=0.3, P<0.01). There was no significant correlation between eosinophil count and the number of coronary arteries showing slow flow.

Conclusion

Patients with SCF have higher blood eosinophil count, and this may play an important role in the pathogenesis of SCF. Elevated baseline eosinophil count may indicate the presence of SCF.

The effects of hyperoxaemia on tissue oxygenation in patients with a nadir haematocrit lower than 20% during cardiopulmonary bypass

Excessive haemodilution and the resulting anaemia during CPB is accompanied by a decrease in the total arterial oxygen content, which may impair tissue oxygen delivery. Hyperoxic ventilation has been proven to improve tissue oxygenation in different pathophysiological states of anaemic tissue hypoxia. The aim of this study was to examine the influence of arterial hyperoxaemia on tissue oxygenation during CPB. Records of patients undergoing isolated CABG with CPB were retrospectively reviewed. Patients with nadir haematocrit levels below 20% during CPB were included in the study. Tissue hypoxia was defined as hyperlactataemia (lactate >2.2 mmol/L) coupled with low ScVO2 (ScVO2 <70%) during CPB. One hundred patients with normoxaemia and 100 patients with hyperoxaemia were included in the study. Patients with hyperoxaemia had lower tissue hypoxia incidence than patients with normoxaemia (p<0.001). Compared with patients without tissue hypoxia, patients with tissue hypoxia had significantly lower PaO2 values (p<0.001) and nadir haematocrit levels (p<0.001). Nadir haematocrit levels <18% (OR: 5.3; 95% CI: 2.67-10.6; p<0.001) and hyperoxaemia (OR: 0.28; 95% CI: 0.14-0.56; p<0.001) were independently associated with tissue hypoxia.

CONCLUSIONS

Hyperoxaemia during CPB may be protective against tissue hypoxia in patients with nadir haematocrit levels <20%.

Role of diclofenac in the prevention of postpericardiotomy syndrome after cardiac surgery

Objective

Postpericardiotomy syndrome (PPS), which is thought to be related to autoimmune phenomena, represents a common postoperative complication in cardiac surgery. Late pericardial effusions after cardiac surgery are usually related to PPS and can progress to cardiac tamponade. Preventive measures can reduce postoperative morbidity and mortality related to PPS. In a previous study, diclofenac was suggested to ameliorate autoimmune diseases. The aim of this study was to determine whether postoperative use of diclofenac is effective in preventing early PPS after cardiac surgery.

Methods

A total of 100 patients who were administered oral diclofenac for postoperative analgesia after cardiac surgery and until hospital discharge were included in this retrospective study. As well, 100 patients undergoing cardiac surgery who were not administered nonsteroidal anti-inflammatory drugs were included as the control group. The existence and severity of pericardial effusion were determined by echocardiography. The existence and severity of pleural effusion were determined by chest X-ray.

Results

PPS incidence was significantly lower in patients who received diclofenac (20% vs 43%) (P<0.001). Patients given diclofenac had a significantly lower incidence of pericardial effusion (15% vs 30%) (P=0.01). Although not statistically significant, pericardial and pleural effusion was more severe in the control group than in the diclofenac group. The mean duration of diclofenac treatment was 5.11±0.47 days in patients with PPS and 5.27±0.61 days in patients who did not have PPS (P=0.07). Logistic regression analysis demonstrated that diclofenac administration (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.18–0.65, P=0.001) was independently associated with PPS occurrence.

Conclusion

Postoperative administration of diclofenac may have a protective role against the development of PPS after cardiac surgery.

Predictors of atrial fibrillation recurrence after cryoballoon ablation

Objective

Cryoballoon ablation (CA) is a safe and efficient method for pulmonary vein isolation in the treatment of paroxysmal atrial fibrillation (AF). There are conflicting results about the predictors of AF recurrence. The aim of this study is to evaluate the role of hematological indices to predict AF recurrence after CA.

Methods

A total of 49 patients (mean age 58.3±12.2 years, 51.02% female) with symptomatic paroxysmal AF underwent CA procedure. One hundred and sixty-eight pulmonary veins were used for pulmonary vein isolation with the second-generation cryoballoon. The hematological samples were obtained before and 24 hours after ablation.

Results

At a mean follow-up of 10.2±2.4 months, the probability of being arrhythmia-free after a single procedure was 86%. Patients with AF recurrence had higher red cell distribution width levels (16.10%±1.44% vs 14.87%±0.48%, P=0.035). The neutrophil/lymphocyte ratio, erythrocyte sedimentation rate, and C-reactive protein levels were detected in the patients with or without recurrence. Left atrial diameter (46.28±4.30 mm vs 41.02±4.10 mm, P=0.002), duration of AF (6.71±4.57 years vs 3.59±1.72 years, P=0.003), and age (65.01±15.39 years vs 54.29±11.32 years, P=0.033) were the other independent predictors of clinical recurrence after CA. Multiple regression analysis revealed that left atrial diameter was the only independent predictor for AF recurrence (P=0.012).

Conclusion

In this study of patients with paroxysmal AF undergoing cryoablation, increased preablation red cell distribution width levels, and not C-reactive protein or erythrocyte sedimentation rate, was associated with a higher rate of AF recurrence. Our results support the role of a preablation, proinflammatory, and pro-oxidant environment in the development of AF recurrence after ablation therapy but suggest that other factors are also important.

The neutrophil to lymphocyte ratio is associated with severity of rheumatic mitral valve stenosis

Background

Rheumatic heart disease (RHD) is a serious health concern in developing countries. Rheumatic mitral stenosis (RMS) is the most long-term sequel in RHD. The neutrophil to lymphocyte ratio (NLR) is a novel marker, and a higher NLR has been associated with poor clinical outcomes in various cardiovascular disorders. We evaluated the availability of NLR to predict severity of mitral stenosis (MS) in patients with RHD.

Methods

We analyzed 300 consecutive patients with RMS. The patients were divided into tertiles according to NLR: 0.85< NLR ≤1.85 (n=100, tertile 1), 1.86≤ NLR ≤2.46 (n=100, tertile 2), and 2.47≤ NLR ≤7.08 (n=100, tertile 3). Patients with RMS were divided into three groups based on the degree of MS as mild, moderate, and severe MS. After the initial evaluation, 187 patients with moderate-to-severe RMS (Group 1) and 113 patients with mild RMS (Group 2) were reassessed.

Results

The patients with severe RMS had significantly elevated NLR, mean platelet volume, and pulmonary artery systolic pressure values compared to patients with moderate and mild MS (P<0.001, P<0.001, P<0.001 respectively). Multivariate binary logistic regression analysis revealed that high levels of NLR was an independent predictor of severe RMS (odds ratio =0.68, P=0.008). Moderate-to-severe RMS incidence was significantly higher among patients in the tertile 3 (odds ratio =2.8, P=0.001).

Conclusion

NLR is a new inflammatory marker and a simple, rapid, and easily accessible prognostic parameter that can be associated with severity of RMS in patients with RHD.

Intracoronary epinephrine in the treatment of refractory no-reflow after primary percutaneous coronary intervention: a retrospective study

Background

Despite the advances in medical and interventional treatment modalities, some patients develop epicardial coronary artery reperfusion but not myocardial reperfusion after primary percutaneous coronary intervention (PCI), known as no-reflow. The goal of this study was to evaluate the safety and efficacy of intracoronary epinephrine in reversing refractory no-reflow during primary PCI.

Methods

A total of 248 consecutive STEMI patients who had undergone primary PCI were retrospectively evaluated. Among those, 12 patients which received intracoronary epinephrine to treat a refractory no-reflow phenomenon were evaluated. Refractory no-reflow was defined as persistent TIMI flow grade (TFG) ≤2 despite intracoronary administration of at least one other pharmacologic intervention. TFG, TIMI frame count (TFC), and TIMI myocardial perfusion grade (TMPG) were recorded before and after intracoronary epinephrine administration.

Results

A mean of 333 ± 123 mcg of intracoronary epinephrine was administered. No-reflow was successfully reversed with complete restoration of TIMI 3 flow in 9 of 12 patients (75%). TFG improved from 1.33 ± 0.49 prior to epinephrine to 2.66 ± 0.65 after the treatment (p < 0.001). There was an improvement in coronary flow of at least one TFG in 11 (93%) patients, two TFG in 5 (42%) cases. TFC decreased from 56 ± 10 at the time of no-reflow to 19 ± 11 (p < 0.001). A reduction of TMPG from 0.83 ± 0.71 to 2.58 ± 0.66 was detected after epinephrine bolus (p < 0.001). Epinephrine administration was well tolerated without serious adverse hemodynamic or chronotropic effects. Intracoronary epinephrine resulted in significant but tolerable increase in heart rate (68 ± 13 to 95 ± 16 beats/min; p < 0.001) and systolic blood pressure (94 ± 18 to 140 ± 20; p < 0.001). Hypotension associated with no-reflow developed in 5 (42%) patients. During the procedure, intra-aortic balloon pump counterpulsation was required in two (17%) patients, transvenous pacing in 2 (17%) cases, and both intra-aortic balloon counterpulsation and transvenous pacing in one (8%) patients. One patient (8%) died despite all therapeutic measures.

Conclusion

Intracoronary epinephrine may become an effective alternative in patients suffering refractory no-reflow following primary PCI.

Relationship between Nadir Hematocrit during Cardiopulmonary Bypass and Postoperative Hyperglycemia in Nondiabetic Patients

<p><b>Background:</b> Hyperglycemia is common after cardiac surgery in both diabetic and nondiabetic patients and is associated with increased morbidity and mortality. Association between nadir hematocrit levels on cardiopulmonary bypass (CPB) and postoperative hyperglycemia is not clear. This study was carried out to determine the relationship between nadir hematocrit during CPB and postoperative hyperglycemia in nondiabetic patients.</p><p><b>Methods:</b> Records of 200 nondiabetic patients undergoing coronary artery bypass grafting operation were retrospectively reviewed. In the first analysis, patients were divided into two subgroups according to the presence or absence of hyperglycemia. Further analysis was made after dividing the patients into 3 subgroups according to nadir hematocrit levels on CPB (less than 20%; 20% to 25%; greater than or equal to 25%).</p><p><b>Results:</b> Compared to patients without hyperglycemia, patients with postoperative hyperglycemia had significantly lower preoperative hematocrit levels (p = 0.004) and were associated with lower nadir hematocrit levels during CPB (p= 0.002). Peak intensive care unit blood glucose levels and number of blood transfusions were significantly higher in patients with nadir hematocrit levels less than 20. (p<0.001 and p<0.001 respectively). Logistic regression analysis demonstrated that nadir hematocrit levels less than 20% (OR 2.9, p=0.009) and allogenic blood transfusion (OR 1.5, p=0.003) were independently associated with postoperative hyperglycemia.</p><p><b>Conclusions:</b> Nadir hematocrit levels on CPB less than 20% and allogenic blood transfusions were independently associated with postoperative hyperglycemia in nondiabetic patients. Patients with a nadir hematocrit levels less than 20 % during CPB should be closely monitored for hyperglycemia in the perioperative period.</p>

Relationship between cobalamin deficiency and delirium in elderly patients undergoing cardiac surgery

BACKGROUND

Delirium is common after cardiac surgery and is independently associated with increased morbidity, mortality, prolonged hospital stays, and higher costs. Cobalamin (vitamin B12) deficiency is a common cause of neuropsychiatric symptoms and affects up to 40% of elderly people. The relationship between cobalamin deficiency and the occurrence of delirium after cardiac surgery has not been examined in previous studies. We examined the relationship between cobalamin deficiency and delirium in elderly patients undergoing coronary artery bypass grafting (CABG) surgery.

MATERIAL AND METHODS

A total of 100 patients with cobalamin deficiency undergoing CABG were enrolled in this retrospective study. Control group comprised 100 patients without cobalamin deficiency undergoing CABG. Patients aged 65 years or over were included. Diagnosis of delirium was made using Intensive Care Delirium Screening Checklist. Delirium severity was measured using the Delirium Rating Scale-revised-98.

RESULTS

Patients with cobalamin deficiency had a significantly higher incidence of delirium (42% vs 26%; P=0.017) and higher delirium severity scores (16.5±2.9 vs 15.03±2.48; P=0.034) than patients without cobalamin deficiency. Cobalamin levels were significantly lower in patients with delirium than patients without delirium (P=0.004). Delirium severity score showed a moderate correlation with cobalamin levels (ρ=-0.27; P=0.024). Logistic regression analysis demonstrated that cobalamin deficiency was independently associated with postoperative delirium (OR 1.93, 95% CI 1.03-3.6, P=0.038).

CONCLUSION

The results of our study suggest that cobalamin deficiency may be associated with increased risk of delirium in patients undergoing CABG. In addition, we found that preoperative cobalamin levels were associated with the severity of delirium. This report highlights the importance of investigation for cobalamin deficiency in patients undergoing cardiac surgery, especially in the elderly.

The effect of hemodialysis on electrocardiographic parameters

BACKGROUND

Cardiovascular complications are the leading causes of premature deaths in hemodialysis patients. Due to rapid changes in volume and electrolyte concentration following dialysis, the some electrocardiographic (ECG) changes or arrhythmias might be seen.

OBJECTIVE

To investigate the acute effects of hemodialysis on the ECG parameters in patients with chronic end-stage renal disease (ESRD).

METHOD

We included the consecutive ESRD patients who underwent a hemodialysis. Before and after hemodialysis, some 12 lead ECG parameters were analyzed by two different cardiologists by using electronic digital caliper device.

RESULTS

A total of 62 patients (mean 52 ± 15 years; 65% male) with ESRD undergoing hemodialysis were recruited to the study. P-wave amplitude, QRS amplitude, QRS duration, QTc dispersion, the sum of amplitudes in V1S + V5R derivations, total QRS amplitude, and duration were significantly greater in posthemodialysis patients compared to the prehemodialysis ones. However, T-wave amplitude and QTc duration were significantly lower in posthemodialysis patients.

CONCLUSION

The ECG changes including prolangated QRS and increased QTc interval after hemodialysis should be kept in mind and assessed carefully in ESRD patients. Prolongation of these parameters may prove to be a further noninvasive marker of susceptibility to ventricular arrhythmias.

The association of serum albumin with coronary slow flow

BACKGROUND

A number of inflammatory markers such as high-sensitivity C-reactive protein (Hs-CRP), interleukin-6 (IL-6), and fibrinogen have been shown to be associated with coronary slow flow (CSF). Our aim was to investigate the relationship between albumin, a long-acting negative acute-phase protein, and CSF.

METHODS

A total of 106 patients with angiographically proven slow coronary flow and 57 control subjects with normal coronary flow were included in the study. Serum levels of Hs-CRP and albumin were measured. CSF was defined by Thrombolysis In Myocardial Infarction (TIMI) frame count (TFC) method.

RESULTS

Serum albumin (s-albumin) was significantly lower in the CSF group (3.79 ± 0.3 vs 4.17 ± 0.3, p < 0.001), whereas Hs-CRP level was significantly higher in the CSF group compared with the controls (1.22 ± 0.79 vs 0.76 ± 0.44, p < 0.001). S-albumin and Hs-CRP were correlated with the mean TFC in the whole study population (r= - 0.574, p < 0.001; r = 0.376, p < 0.001, respectively). Hs-CRP and low s-albumin were found to be significant predictors of CSF in the multivariate analysis. The comparison of receiver-operating characteristics curves for s-albumin and Hs-CRP demonstrated that s-albumin was the strongest predictor of CSF.

CONCLUSIONS

We found that s-albumin levels decreased and Hs-CRP levels increased in patients with CSF. S-albumin was also found to have superior predictive value than Hs-CRP for diagnosing CSF. S-albumin, an inexpensive and easily measurable laboratory variable, may be a useful predictor of CSF, especially when other reasons which alter its serum levels were excluded.

A rare manifestation of atrial fibrillation in the presence of Wolff-Parkinson-White syndrome: tachycardia-induced cardiomyopathy

We report a 68-year-old man who presented with heart failure and atrial fibrillation (AF) with rapid ventricular response and wide QRS complexes. Tachycardia-induced cardiomyopathy (TIC) due to persistent AF developing on the basis of Wolff-Parkinson-White (WPW) syndrome was considered. Signs and symptoms of heart failure improved with restoration of sinus rhythm. This case suggested that persistent AF in a patient with WPW syndrome is one of the rare causes of TIC.

Prediction of coronary artery disease severity using CHADS2 and CHA2DS2-VASc scores and a newly defined CHA2DS2-VASc-HS score

As the CHADS2 and CHA2DS2-VASc scores include similar risk factors for the development of coronary artery disease (CAD), they may provide crucial information regarding the severity of coronary artery lesions and the risk of thromboembolism. To increase the likelihood of determining CAD severity, we formulated the CHA2DS2-VASc-HS score comprising hyperlipidemia and smoking in addition to the components of the CHA2DS2-VASc score and male instead of female gender. We aimed to investigate whether these 3 risk scores can be used to predict CAD severity. A total of 407 consecutive patients who underwent coronary angiography were enrolled in the study. Presence of >50% stenosis in a coronary artery was assessed as significant CAD. Of the patients, 87 had normal coronary angiograms and served as group 1. The remaining 320 patients with coronary stenosis were further classified into 2 groups according to CAD with stenosis of <50% or ≥50%: 123 patients with mild CAD as group 2 and 197 patients with severe CAD as group 3. The CHADS2, CHA2DS2-VASc, and CHA2DS2-VASc-HS scores were significantly different among the 3 groups. The CHADS2, CHA2DS2-VASc, and CHA2DS2-VASc-HS scores correlated significantly with the number of diseased vessels (r = 0.406, p <0.001; r = 0.308, p <0.001; and r = 0.533, p <0.001, respectively) and the Gensini score (r = 0.383, p <0.001; r = 0.300, p <0.001; and r = 0.500, p <0.001, respectively). The CHA2DS2-VASc-HS score was found to be the best scoring scheme to predict CAD severity in the area under the curve comparison of these scoring systems. For prediction of severe CAD, the cut-off value of CHA2DS2-VASc-HS score was >2 with a sensitivity of 85.2% and a specificity of 57.5% (area under the curve 0.802, 95% confidence interval 0.760 to 0.839, p <0.001). In conclusion, our findings suggest that the CHADS2, CHA2DS2-VASc, and especially CHA2DS2-VASc-HS scores could be considered predictive of the risk of severe CAD.

Increased platelet distribution width is associated with ST-segment elevation myocardial infarction and thrombolysis failure

We investigated 2 hypotheses: (1) a relationship between platelet indices and stable coronary artery disease (CAD) and acute ST-segment elevation myocardial infarction (STEMI) and (2) a relationship between platelet indices on admission and thrombolysis outcomes in patients with STEMI. A total of 260 patients were enrolled. The white blood cell (WBC) and platelet distribution width (PDW) were found to be increased in patients with STEMI (P for both < .001). White blood cell and PDW were independent predictors of acute STEMI. Mean platelet volume (MPV) and PDW were significantly higher in the thrombolysis failure group than in the thrombolysis success group (9.9 ± 1.8 vs 9.2 ± 1.5 fL, P = .021 and 17.7 ± 1.0 vs 16.4 ± 2.1 fL, P < .001, respectively). Mean platelet volume and PDW were independent predictors of thrombolysis failure. Patients with acute STEMI had higher PDW than did patients with stable CAD. In addition, higher PDW and MPV seem to correlate with thrombolysis failure in patients with STEMI.

Serum paraoxonase, arylesterase activity and oxidative status in patients with obstructive sleep apnea syndrome (OSAS)

INTRODUCTION

The aim of this study was to evaluate the serum paraoxonase (PON), arylesterase activities, lipid hydroperoxide (LOOH), sulfhydryl (-SH), and ceruloplasmin (Cp) levels, total antioxidant status (TAS), total oxidant status (TOS), and oxidative stress index (OSI) in adults with obstructive sleep apnea syndrome (OSAS) and to determine whether these oxidant and antioxidant levels can be used as OSAS markers. The results were compared with measurements from healthy control subjects.

METHODS AND METHODS

This study was a prospective, controlled trial including 26 OSAS patients and 35 healthy controls (61 subjects total). Peripheral venous blood samples were taken from the OSAS patients and from the healthy volunteers. The serum PON, arylesterase activities LOOH, -SH, Cp, TAS, TOS, and OSI levels were measured.

RESULTS

LOOH and Cp levels were higher in the OSAS group than in the control group (p < 0.01). The -SH levels were lower in the OSAS group than in the control group (p < 0.01). The PON and arylesterase enzyme activity levels were lower in the OSAS group than in the control group (p < 0.05). The TOS and OSI levels were significantly higher in the OSAS group (p < 0.01), while their TAS levels were significantly lower (p < 0.01) compared with the control group.

CONCLUSIONS

Patients with OSAS have increased systemic oxidative stress and reduced levels of circulating antioxidant enzymes. Oxidative stress appears to be an underlying condition associated with OSAS.

The role of high frequency tympanometry in newborn hearing screening programme

BACKGROUNDS AND OBJECTIVE

The hearing assessment of the newborns ideally should detect both middle and inner ear functions. The aim of this study is to control the association between otoscopic evaluation, multifrequency tympanometry and TEOAE results.

METHODS

Fifty new-borns otherwise healthy were tested after the otolaryngological evaluation by 226 and 1000 Hz tympanometries and transient evoked otoacoustic emissions (TEOAE's). The study was performed in three steps and 17 babies that could not pass from the first step they were tested in the second step with the same tests (226 Hz and 1000 Hz tympanometry and TEOAE) The babies that could not pass from the second step were evaluated by multifrequency tympanometries, TEOAE and acoustic brainstem responses (ABR) at the third step.

RESULTS

The association between the results obtained from otoscopic evaluation, multifrequency tympanometry and TEOAE were assessed. We found that 1000 Hz tympanometry results were more sensitive and gives more correlated with TEOAE and otoscopic evaluation.

CONCLUSIONS

Multifrequency tympanometry can detect the middle ear pathologies of the infants sensitively and should be a part of neonatal hearing screening test battery.