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Giriş ve amaç: Akut bacak iskemisi (ABİ) en sık görülen acil vasküler girişimlerden biridir ve kardiyovasküler mortalite ve amputasyonlarla yüksek oranda ilişkilidir. Başarılı endovasküler tedavi (EVT) stratejilerine ve cerrahi girişimlere rağmen ABİ’li hastalarda mortalite ve morbidite oranları hala yüksek kalmaya devam etmektedir. Bu çalışmada, EVT veya cerrahi embolektomi ile tedavi edilen ABİ’li hastalarda uzun dönem sağkalım ve ampütasyon oranlarını araştırmayı amaçladık. Yöntemler: Çalışmamıza 2016-2020 yılları arasında hastanemizde ABİ tanısı alan 86 ardışık hasta retrospektif olarak dahil edildi. ABİ tanısı renkli doppler ultrasonografi veya bilgisayarlı tomografik anjiyografi ile konuldu. Antibiyotik tedavisi gerektiren akut enfeksiyonu olan hastalar, kronik inflamatuar hastalık, son dönem karaciğer yetmezliği ve malignitesi olan hastalar çalışmaya dahil edilmedi. Hastalar cerrahi yöntemle tedavi edilenler (grup 1) ve endovasküler yöntemlerle revaskülarize edilenler (grup 2) olacak şekilde iki gruba ayrıldı. Bulgular: Çalışmanın ortalama takip süresi 19 ay (1-26) idi. Cerrahi gruptaki ve EVT grubundaki hastaların tüm nedenlere bağlı mortalite ve amputasyon oranları istatistiksel olarak benzerdi (sırasıyla %14,3'e karşı %27,3, p:0,139 ve %14,3'e karşı %9,1, p: 0,453). Kaplan-Meier sağkalım analizi, EVT ile cerrahi grup arasında tüm nedenlere bağlı mortalite ve amputasyon açısından anlamlı bir farklılık göstermedi (log-rank p = 0.649). Çok değişkenli lojistik regresyon analizinde, Rutherford evresi, konjestif kalp yetersizliği ve CRP / albümin oranı (CAR), amputasyon ve tüm nedenlere bağlı mortalitenin bağımsız bir öngördürücüsü olabileceği bulunmuştur. Sonuç: Çalışmamızda akut bacak iskemisi olan hastalarda EVT ve cerrahi embolektominin benzer uzun dönem sonuçları olduğunu gözlemledik. Ayrıca Rutherford klinik evresi, konjestif kalp yetersizliği ve yüksek CAR'ın mortalite ve amputasyonun bağımsız bir belirleyicisi olabileceğini gözlemledik. Bu verilerin daha büyük ve prospektif çalışmalarla desteklenmesi gerekmektedir.

Introduction: This study was designed to evaluate the relationship between left atrial volume index, which is an important indicator of left ventricular diastolic dysfunction, and electrocardiographic parameters such as P wave duration, P wave dispersion (PWDISP), P wave terminal force (PWTF), and P wave peak time (PWPT) in hypertensive patients. Patients and Methods: A total of 58 patients with a diagnosis of hypertension between June 2017 and April 2018 were included in this retrospective study. Age-sex matched 58 healthy subjects constituted the control group. The patients without diastolic dysfunction and stage I diastolic dysfunction were included in the normal left atrial pressure (NLAP) group, while stage II and stage III diastolic dysfunction patients constituted the high left atrial pressure (HLAP) group. Results: The PWDmax, PWDISP, and PWPT which are calculated from the lead DII (PWPTDII) were found to be longer in the group of hypertensive patients (p< 0.05, for all). Electrocardiographic parameters of PWDmax, PWDISP, PWTF, PWPTDII, and PWPTVI were found to be longer in patients with HLAP. Both PWPTVI (p= 0.008 r= 0.395) and PWPTDII (p< 0.001 r= 0.456) were significantly correlated with left atrial volume index. Conclusion: In this study, the relationship between PWPT and diastolic dysfunction was revealed for the first time in the literature. In addition, the PWPT was found to be increased in patients with increased left atrial pressure (LAP). Our findings deserve attention because electrocardiography is an inexpensive and easily accessible diagnostic method that can be used to detect diastolic dysfunction in hypertensive patients.

Introduction: Inflammation and malnutrition may trigger heart failure development and progression (HF). However, the relationship of the modified Glasgow prognostic score (mGPS), which is derived from C-reactive protein and albumin with mildly reduced ejection fraction HF (HFmrEF), is not well-known. We aimed to determine whether the modified Glasgow prognostic score (mGPS) is helpful for the prediction of all-cause mortality in patients with HFmrEF. Patients and Methods: Patients with HFmrEF admitted to our outpatient clinic between January 2016 and January 2020 were enrolled. All-cause mortality was defined as the primary endpoint. The mGPS was calculated and, its association with overall survival was determined. Results: Data were analyzed for 259 patients. The mGPS≤ 1 in 172 (66%), and 2 in 87 (34%) patients, respectively. Higher mGPS was related to worse results of routine biomarkers associated with prognosis, especially NT-proBNP [777 (112-4564) pg/mL vs. 350 (65-3521) pg/mL, respectively, p< 0.0001)]. In multivariable Cox model, NT-proBNP [1.83 (1.32-2.55), p< 0.0001], mGPS 2 vs. ≤1 [2.43 (1.2-4.93), p= 0.013], and coronary artery disease (CAD) [3.15 (1.46-6.82), p= 0.003] were found to be independently associated with all-cause mortality. Conclusion: The immune-nutritional score mGPS predicts mortality during long-term follow-up of patients with HFmrEF. The mGPS might be used for risk status assessment of HFmrEF.

Introduction: Rheumatic mitral valve disease (RMVD) is associated with autoimmune heart valve injury. Parathyroid hormone (PTH) and vitamin D are two essential molecules that have effects on the immune system. In this study, we aimed to evaluate the relationship between PTH and vitamin D in patients with RMVD. Patients and Methods: We investigated 81 patients with RMVD and 75 healthy subjects. According to Wilkins score, baseline clinical, laboratory, and echocardiographic parameters were recorded, and all RMVD patients were analyzed. Multivariate logistic regression analysis was performed between the groups. Results: Vitamin D levels were significantly low in the RMVD group. Patients were stratified according to Wilkins score [Wilkins score Conclusion: This study showed that vitamin D levels were low in patients with RMVD. According to the Wilkins score, PTH levels were significantly high in patients with a high Wilkins score. Changes in PTH and vitamin D levels may trigger inflammation and be responsible for valve damage.

Coronary artery calcification is a cornerstone marker for coronary atherosclerosis. Therefore, the calculation of the coronary artery calcium score has become a routine method in diagnosing coronary artery disease in recent years. Monocyte to high-density lipoprotein cholesterol ratio reflects proatherogenic and antiatherogenic balance, and this ratio is associated with coronary atherosclerosis and cardiovascular events. This study aimed to investigate the value of monocyte to high-densitylipoprotein cholesterol ratio in predicting coronary atherosclerosis, which coronary artery calcium score determines.A total of 276 patients with chest pain who underwent coronary computed tomography angiography were enrolled in the study. The patients were divided into 3 groups according to coronary artery calcium score [coronary artery calcium score=0 for very low risk (n=121), coronary artery calcium score=1-99 for low risk (n=100), coronary artery calcium score ≥ 100 for moderate-high risk (n=55)]. The monocyte to high-density lipoprotein cholesterol ratio, neutrophil-to-lymphocyte ratio, systemic immune-inflammation index, and plateletto-lymphocyte ratio were calculated from venous blood samples.Monocyte to high-density lipoprotein cholesterol ratio values were significantly higher in patients with moderate-high coronary artery calcium score (1.29 ± 0.59 vs 1.41 ± 0.56 vs 1.56 ± 0.58, P =.009). However, there were no differences between the groups in terms of other inflammatory markers (neutrophil-to-lymphocyte ratio, systemic immune-inflammation index, and platelet-to-lymphocyte ratio). Age (odds ratio: 1.178; 95% CI: 1.107-1.253; P.001), dyslipidemia (odds ratio: 14.252; 95% CI: 5.459-37.211; P.001), smoking (odds ratio: 2.893; 95% CI: 1.317-6.358; P=.008), and monocyte to high-density lipoprotein cholesterol ratio (odds ratio: 2.082 per 1-point increase; 95% CI: 1.016-4.268; P=.045) were independent predictors of coronary artery calcium score in multivariate analysis.Our data showed that high monocyte to high-density lipoprotein cholesterol ratio is significantly associated with increased coronary artery calcium score. Monocyte to highdensity lipoprotein cholesterol ratio indicates that it can be applied easily and swiftly in clinics to help predicting the coronary artery disease.

Background Peripheral artery disease (PAD) is part of the systemic atherosclerotic process that is highly associated with cardiovascular diseases. Despite successful endovascular treatment (EVT) strategies, mortality and morbidity rates still remain higher in PAD patients. C-reactive protein (CRP) and albumin are biomarkers of inflammation and malnutrition that play key roles in the progression of peripheral arterial disease. In this study, we aimed to investigate the relationship between CRP-to-albumin ratio (CAR) and mortality and amputation-free survival in patients with PAD after successful EVT. Method Our study enrolled 149 consecutive patients who underwent EVT on atherosclerotic obstruction of iliac, femoral, popliteal and/or below-knee arteries with the clinical features of PAD and/or chronic limb-threatening ischaemia between January 2015 and January 2020. Clinical and prognostic follow-up of patients had been done at the outpatient clinic and were collected from institution’s medical records. Results The mean follow-up period was 22 months (14–40). All-cause mortality and amputation rates of patients in the high CAR group were significantly higher than those in the low CAR group (21.3% vs. 6.8% and 18.7% vs. 5.4%, respectively). Kaplan–Meier survival analysis showed significantly better survival for patients in the low CAR group (log-rank p = 0.0058). In multivariate logistic regression analysis, CAR was found to be an independent predictor of amputation and all-cause mortality even after adjusting for other confounding risk factors. ROC curve analysis revealed the optimal cut-off value of CAR for predicting all-cause mortality and amputation to be >1.476 with a sensitivity of 48.5% and specificity of 94.0%. Conclusion The inflammatory state reflected by CAR levels was strongly associated with all-cause mortality and amputation after EVT in patients with PAD. Furthermore, CAR was found to be an independent predictor of these clinical outcomes after adjusting for other clinically associated parameters.

Coronary artery fistulas (CAFs) are described as abnormal communications between a coronary artery and cardiac chambers, or other vascular structures. The two types of CAFs are defined as type I (singular fistula) and type II (microfistulas). Even though various electrocardiographic changes have been previously described in CAF patients, coronary-artery microfistulas causing ST-segment elevation in diverse locations have not been reported. We describe a case report of an adult patient who presented with acute inferior myocardial infarction due to coronary-artery microfistulas. During the hospital stay, the patient re-experienced chest pain, and control electrocardiography revealed ST-segment elevation in the I and AVL leads along with reciprocal ST-segment depression in the inferior precordial leads. Although CAFs are clinically rare, they can have important clinical consequences. Microfistulas should be kept in mind as a cause of ST elevation myocardial infarction in some patients.

Because the phenomenon of no reflow has a poor prognosis in ST-segment elevation myocardial infarction (STEMI) patients and the atherogenic index of plasma (AIP) has been shown to be a strong predictor of coronary heart disease, we aimed to investigate the relationship between AIP and no-reflow in patients with acute STEMI who underwent primary percutaneous coronary intervention (PCI). A total of 763 consecutive STEMI patients (648 men; mean age 58 ± 12 years) who underwent primary PCI were recruited for this study. The patients were classified into a reflow group (n = 537) and a no-reflow group (n = 226) according to the postprocedural angiographic features of thrombolysis in the myocardial infarction flow of the infarct-related artery. The AIP value was significantly higher in the no-reflow group than in the reflow group [0.50 (0.38–0.65) vs. 0.39 (0.25–0.49) p

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 relationship between acute kidney injury (AKI) and C-reactive protein (CRP) and albumin has been previously demonstrated in patients with ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI). However, to our knowledge, CRP to albumin ratio (CAR), a newly introduced inflammation-based risk score, has not yet been studied. In this study, we aimed to investigate the possible relationship between the CAR and AKI.A total of 815 consecutive STEMI patients treated with pPCI were reviewed.One hundred ten 110 (13.5%) patients developed AKI in the study population. The subjects were divided into two groups according to AKI development. The in-hospital mortality rate was higher in patients with AKI than those without AKI (15.5% vs. 1.3%; p0.001). The patients with AKI had significantly higher mean value of CRP and CAR (0.29 [0.16-0.50] vs. 0.55 [0.37-1.05]; p0.001) and lower mean levels of albumin than those without AKI. Age, diabetes mellitus, haematocrit, left ventricular ejection fraction, hypotension, and CAR (Odds ratio [OR]2.307, 95% confidence interval [CI] 1.397-3.809, p=0.001) were independent predictors of AKI.The CAR may be a useful inflammation-based risk score to predict AKI development in STEMI patients treated with pPCI.

Objective: An increased left atrial volume index (LAVI) is related to increased mortality in hemodialysis patients. In the present study, we evaluated the association between the LAVI and the P wave peak time (PWPT), a newly introduced electrocardiographic parameter, in hemodialysis patients. Methods: The study population was made up of 79 hemodialysis patients with a mean age of 53 ± 18 years (55.7% were males). These patients were divided into a normal LAVI (≤28 mL/m2) group (n = 45) and an increased LAVI (>28 mL/m2) group (n = 34). The demographic, clinical, laboratory, echocardiographic, and electrocardiographic variables of the groups were compared. Results: The P wave terminal force from lead V1, P wave dispersion and PWPTs obtained from leads V1 and D2 (PWPTD2) were significantly higher in the patients with increased LAVIs. In multivariable analysis, only the PWPTD2was an independent predictor of an increased LAVI (odds ratio = 1.117, 95% CI = 1.052–1.185, p < 0.001). The receiver-operating characteristic curve analysis showed that the best PWPTD2 cutoff value for predicting an increased LAVI was 60 ms, with a sensitivity of 76.5% and a specificity of 66.7% (area under the curve = 0.736, 95% CI = 0.625–0.829, p < 0.001). Conclusion: This study showed that a prolonged PWPTD2 was independently associated with an increased LAVI in hemodialysis patients. Therefore, measuring the PWPTD2 duration on an electrocardiogram may help define high-risk hemodialysis patients with increased LAVIs.

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 DII and V1. Results The PWPTs in the leads DII and V1 were significantly longer in the group with severe CAD (71 ± 13 vs. 61 ± 12, p 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.

Objectives Pulmonary embolism (PE) is one of the leading causes of cardiovascular mortality worldwide. Electrocardiography (ECG) may provide useful information for patients with acute PE. In this study, we aimed to investigate the diagnostic value of the QRS duration and RS time in inferolateral leads in patients admitted to the emergency department, and pre-diagnosed with acute PE. Methods We retrospectively enrolled 136 consecutive patients, admitted to the emergency department, pre-diagnosed with the clinical suspicion of acute PE, and underwent computerized tomographic pulmonary angiography (CTPA) to confirm the PE diagnosis. The study subjects were divided into two groups according to the presence or absence of PE, and the independent predictors of PE were investigated. Results Sixty-eight patients (50%) had PE. Patients with PE had a longer RS time. Among the ECG parameters, only RS time was an independent predictor of PE (OR: 1.397, 95% CI: 1.171–1.667; p Conclusion As a novel ECG parameter, RS time could be measured for each patient. A longer RS time can be a very useful index for diagnosing acute PE as well as for estimating the RV end-diastolic diameter and SPAP.

Introduction: Stent restenosis remains a clinical challenge for patients with ischemic heart disease, since it is associated with repeated coronary interventions as well as higher hospitalization rates and medical costs. Inflammation plays a significant role. Although an association between stent restenosis, increased C-reactive protein (CRP) and decreased albumin levels has been previously reported, no studies have investigated the ability of the CRP/albumin ratio to predict stent restenosis. Methods: This retrospective study included 448 patients who had previously undergone primary percutaneous coronary intervention and who were referred for subsequent reintervention due to recurrence of anginal symptoms. The study population was divided into two groups based on whether the patient had developed stent restenosis. They were then stratified into three groups according to their CRP/albumin ratio. Results: Out of 448 patients, stent restenosis was observed in 24.5% (n=110), as determined by coronary angiography. Patients with stent restenosis had a higher CRP/albumin ratio, greater platelet distribution width (PDW), higher CRP levels, and lower levels of both high-density lipoprotein (HDL) cholesterol and serum albumin. The CRP/albumin ratio (OR: 2.289, 95% CI: 1.056-4.959; p=0.036), stent diameter, PDW and HDL cholesterol levels were found to be independent predictors of stent restenosis. A ROC curve comparison demonstrated that the CRP/albumin ratio was a better predictor of restenosis than either albumin and CRP individually, but it was not better than PDW and HDL cholesterol. Conclusion: As a novel inflammation-based risk score, the CRP/albumin ratio may be an easily accessible marker for assessment of stent restenosis risk. Resumo: Objetivo: A reestenose de stent permanece como um desafio clínico em doentes com cardiopatia isquémica. A reestenose de stent está associada a intervenções coronárias recorrentes bem como a aumento de internamentos e de custos médicos. A inflamação tem um papel significativo. Embora a associação entre reestenose de stent e o aumento dos níveis de proteína C-reativa (PCR) e a diminuição dos níveis de albumina tenham sido previamente registados, nenhum estudo pesquisou a possibilidade da PCR/albumina prever um diagnóstico de reestenose de stent. Métodos: Este estudo retrospetivo incluiu 448 doentes que tinham sido previamente submetidos a intervenção coronária percutânea primária e que foram referidos para reintervenção posterior devido a ressurgimento dos sintomas de angina. A população do estudo foi dividida em dois grupos com base no facto do doente ter desenvolvido reestenose de stent. Posteriormente, foram estratificados em três grupos de acordo com as relações PCR/albumina. Resultados: De um grupo de 448 doentes, a reestenose de stent foi observada em 24,5% (n = 110), conforme determinado por avaliação através de angiografia coronária. Os doentes com reestenose de stent apresentaram uma relação PCR/albumina mais elevada, variação maior do diâmetro das plaquetas (DP), níveis mais elevados de PCR e níveis mais baixos de colesterol de lipoproteínas de alta densidade (HDL) e de albumina sérica. Os níveis da relação PCR/albumina (OR: 2,289, IC 95%:1,056 – 4,959; p = 0,036), o diâmetro do stent, a variação maior do DP e o colesterol HDL foram considerados fatores preditores independentes da restenose de stent. A comparação das curvas ROC demonstrou que a relação PCR/albumina constituiu um fator preditor melhor do que a albumina e a PCR, isoladamente, não sendo, no entanto, melhor do que o DP e o colesterol HDL. Conclusão: Como novo score de risco baseado em inflamação, a relação PCR/albumina pode ser um marcador facilmente acessível para a avaliação do risco de reestenose de stent. Keywords: Stent restenosis, C-reactive protein/albumin ratio, ST-segment elevation myocardial infarction, Inflammation, Palavras chave: Reestenose de stent, Proteína C reativa/albumina, Enfarte do miocárdio com elevação do segmento ST, Inflamação

Although the prognostic efficacy of C-reactive protein (mg/L) and albumin levels (g/L) has been previously associated with poor prognosis in ST elevation myocardial infarction (STEMI), to the best of our knowledge, the prognostic efficacy of C-reactive protein/Albumin ratio (CAR) (mg/g) has not been investigated yet. Thus, this study aimed to investigate the potential efficacy of the CAR in predicting prognosis in STEMI patients.We conducted a detailed investigation of 2437 patients with first STEMI treated with a primary percutaneous coronary intervention. After evaluation regarding to exclusion criteria, 2243 patients were found to be eligible for analysis. The mean follow-up of the study was 34 ± 15 months.The median CAR value of the study population was 2.70 (range: 1.44-4.76), and the patients were divided into three tertiles according to their CAR values. Kaplan-Meier survival analysis showed significantly lower in-hospital and long-term survival rates for the patients in a high CAR tertile. In addition, the CAR was found to be an independent predictor of all-cause mortality (Hazards ratio: 1.033, 95% Confidence Interval: 1.007-1.061, p = .033), and the prognostic performance of the CAR was superior to that of C-reactive protein, albumin, and neutrophil to lymphocyte ratio in the receiver operating characteristic curve comparison.The CAR, a newly introduced inflammation-based risk index, was found to be a potentially useful prognostic tool for predicting a poor prognosis in STEMI patients. However, this finding needs to be validated in the future prospective studies.

Contrast-induced nephropathy (CIN) is a prevalent and serious complication after primary percutaneous coronary intervention (pPCI). Although the association between serum osmolarity and chronic kidney disease is well established, its relation to CIN in patients with ST-segment elevation myocardial infarction (STEMI) undergoing pPCI needs to be elucidated. We evaluated the predictive value of serum osmolarity for CIN development in patients with STEMI (n = 768) undergoing pPCI. Serum osmolarity on admission was calculated. The study population was divided into 2 groups according to CIN development, and both groups were compared according to clinical, laboratory, and demographic features, including the serum osmolarity. Serum osmolarity was significantly higher in patients with CIN than in those without CIN (278 [8] vs 284 [9]; P = .024). Serum osmolarity (odds ratio: 1.052; 95% confidence interval: 1.018-1.086; P = .002), hemoglobin, contrast media volume, creatinine on admission, basal SYNergy between PCI with TAXus and cardiac surgery II score, and left ventricular ejection fraction were found to be independent predictors of CIN. Serum osmolarity (given the simple calculation of this parameter on admission) can be useful to define patients with STEMI undergoing pPCI who are more likely to develop CIN.

Purpose We aimed to evaluate the relationships between the severity of peripheral arterial disease (PAD) and immune-nutritional status, as quantified by the prognostic nutritional index (PNI), controlling nutritional status score (CONUT), and modified Glasgow prognostic score (mGPS). Methods and results One hundred forty-eight patients with severe lower extremity PAD diagnosed by angiography constituted the study population. All patients had at least one severe superficial femoral arterial disease (SFA). According to the presence of a chronic total occlusion in SFA (SFA CTO), the study population was divided into two groups. Patients with SFA CTO (n: 84) had a significantly lower PNI(43.4 ± 4.8 vs. 49.1 ± 4.7, p

Coarctation of the aorta (CoA ) is a well-known congenital heart disease (CHD) , which is often associated with several other cardiac and vascular anomalies, such as bicuspid aortic valve (BAV) and ventricular septal defect. BAV is the most common CHD whereas Pacman heart (incomplete muscular ventricular septal defect) is rare congenital deformity. We found a coexistence of Pacman heart, CoA and BAV in a 21- year- old male patient presenting with headache and high blood preesure. This extremely rare combination of these three congenital cardiac abnormalities occurring in the same patient has not been reported yet.

Background Peripheral arterial disease is associated with increased cardiovascular mortality and morbidity. C-reactive protein and albumin are biomarkers of inflammation and malnutrition that play key roles in the pathophysiological pathways involved in the progression of atherosclerosis and peripheral arterial disease. In this study, we aimed to assess the relationship between C-reactive protein to albumin ratio and the suprapopliteal peripheral arterial disease severity and complexity as assessed by TransAtlantic Inter-Society Consensus-II (TASC-II) classification. Method Our study enrolled 224 consecutive patients referred for peripheral angiography with the clinical features of possible peripheral arterial disease at a tertiary care center between January 2016 and September 2019. Level of disease and lesion characteristics were defined with reference to angiographic findings according to the TASC-II classification. Results C-reactive protein/albumin ratio levels were significantly higher in TASC-II class C and D than in TASC-II class B patients with a median level of 1.8 to 2.1 vs 1.4, respectively ( p = 0.018). In multivariate regression analysis, C-reactive protein to albumin ratio remained an independent predictor of severe peripheral arterial disease. The predictive performance of C-reactive protein to albumin ratio, C-reactive protein, and albumin were compared by Receiver Operating Characteristic curve analysis. C-reactive protein to albumin ratio surpassed C-reactive protein and albumin in predicting peripheral arterial disease severity and complexity. A level of C-reactive protein to albumin ratio > 0.14 predicted a higher grade of suprapopliteal TASC-II class with sensitivity and specificity of 68.2% and 56.0%, respectively. Conclusion C-reactive protein to albumin ratio was strongly associated with peripheral arterial disease severity and complexity, as assessed by TASC-II classification. Also, C-reactive protein to albumin ratio was found to be a more accurate marker than C-reactive protein and albumin alone in predicting more severe and complex lesions in patients with peripheral arterial disease.

Objective: Contrast-induced acute kidney injury (CI-AKI) is a well-known and life-threating complication in patients with ST-elevation myocardial infraction (STEMI) after primary percutaneo...

Objective Many studies have examined the capability of electrocardiography (ECG) changes to predict the severity and prognosis of patients with acute pulmonary embolism (APE). RS time in ECG is potentially valuable in evaluating the prognosis of APE. In our study, we aimed to assess the predictive value of RS time, which is a novel electrocardiographic parameter of one-month mortality of APE. Methods This retrospective study included 216 patients who were diagnosed with APE by pulmonary computed tomography angiography. RS time was measured from the ECG (inferolateral leads) at the time of hospital admission using a computer program ( imagej.nih.gov/ij /). The patients were divided into two groups according to the median values of RS time: the group with RS time ≤ 60 msec (n:108) and the group with RS time > 60 msec (n:108). The groups were compared in terms of mortality. Results In our study, the one-month mortality was 15.3% (33) in the patients hospitalized with APE. In the multivariate analysis, RS time prolongation (HR: 1.037; 95%CI: 1.005–1.065; p = .02) was independently correlated with mortality. The ROC curve analysis revealed that RS time > 64.8 msec predicted the one-month mortality in APE with a sensitivity of 68.6% and a specificity of 73.9% (AUC: 0.708; 95% CI: 0.643–0.768; p Conclusion As a novel ECG parameter, RS time could be measured for each patient with APE. Prolongation of RS time could be a useful index for predicting the one-month mortality of patients diagnosed with APE.

Introduction: Multiple studies have shown the relationship between heart failure (HF) and development ofdepression. Several studies have demonstrated worse perception of quality of life among patients with type 2diabetes mellitus (T2DM). We aimed to assess the association between glycated hemoglobin (HbA1c) levelsand depression severity in patients with diabetic HF.Patients and Methods: Between July 2015 and June 2016, 179 patients with HF (left ventricular ejectionfraction < 35%) and T2DM were included in the study. Blood samples for HbA1c were obtained from patientswith T2DM. The severity of depression was assessed using the Beck Depression Inventory (BDI). Patientswith depression were classified as follows: minimal with score 0-13 (group I), mild with score 14-19 (groupII), moderate with score 20-28 (group III), and severe with score 29-63 (group IV).Results: The median age of the study population was 64 (57-75) years (98 females and 81 males). There wasno significant difference between the groups regarding the frequency of hypertension and gender. There wasa significant positive correlation between BDI and HbA1c levels in patients with HF (r= 0.488, p< 0.001).According to the analysis performed between the groups, HbA1c values were found to be significantly higher ingroup IV than in groups I, II, and III (6.0 ± 1.47, 6.4 ± 0.6, 7.03 ± 0.7, and 7.6 ± 1.23, respectively; p< 0.001),which indicate the association between severity of depression and HbA1c level.Conclusion: We detected a significant association between BDI and HbA1c level in patients with chronic HFwith T2DM. Therefore, more strict control of blood glucose level may improve quality of life and decreasedepressive symptoms in patients with diabetic HF., Giriş: Birçok çalışma kalp yetmezliği ile depresyon gelişimi arasındaki ilişkiyi göstermiştir. Bazı çalışmalartip 2 diabetes mellitus (DM) olanlarda yaşam kalitesinin bozulduğunu göstermiştir. Diyabetik kalp yetmezliklihastalarda HbA1c düzeyleri ile depresyon arasındaki ilişkiyi değerlendirmeyi amaçladık.Hastalar ve Yöntem: Temmuz 2015 ve Haziran 2016 tarihleri arasında, 179 Tip 2 DM’li kalp yetmezliğiolan (LV-EF < %35) hastalar çalışmaya dahil edildi. Tip 2 DM’li hastalardan HbA1c için kan örneklerialındı. Depresyonun şiddeti Beck Depresyon Envanteri (BDE) kullanılarak değerlendirildi. Depresyonuolan hastalar aşağıdaki gibi sınıflandırıldı: minimal skor 0-13 (grup I), hafif skor 14-19 (grup II), orta skor20-28 (grup III) ve şiddetli skor 29-63 (grup IV).Bulgular: Çalışma popülasyonunun medyan yaşı 64 (57-75) idi (kadın: 98, erkek: 81). Hipertansiyon ve cinsiyetsıklığı açısından gruplar arasında anlamlı fark yoktu. BDE skorlama sistemine göre sınıflandırılan hastalarınsayısı, I ila IV. gruplarda sırasıyla 42, 45, 46 ve 46 idi. Kalp yetmezliği olan hastalarda BDE ve HbA1c düzeyleriarasında anlamlı pozitif korelasyon vardı (r= 0.488, p< 0.001). Gruplar arasında yapılan analizlere göre HbA1cdeğerleri grup 4 te grup I, II ve III’e göre anlamlı olarak yüksek bulundu (6.0 ± 1.47, 6.4 ± 0.6, 7.03 ± 0.7, 7.6 ±1.23, sırasıyla, p< 0.001).Sonuç: Tip 2 DM’li kronik kalp yetmezlikli hastalarda BDE ve HbA1c düzeyleri arasında anlamlı ilişki saptadık. Bu nedenle, kan glukoz seviyesinindaha sıkı kontrolü, diyabetik kalp yetmezlikli hastalarda yaşam kalitesini artırabilir ve depresif belirtileri azaltabilir.

This study aimed to investigate the diagnostic value of QRS and S wave variation in patients admitted to the emergency department with suspicion of acute pulmonary embolism (APE).Computerized tomographic pulmonary angiography (CTPA) was performed in 118 consecutive patients to evaluate patients with suspected APE, and 106 subjects with appropriate electrocardiogram and CT images constituted the study population.Using CTPA, APE was diagnosed in 48.1% (n:51) of the study population. The comparison of patients with APE and those without APE revealed that increased heart rate, right axis deviation of QRS axis, complete or incomplete right bundle branch block, prominent S wave in lead D1, increased QRS duration, percentage of QRS (9,8[4,8-19,0] vs 3,8[2,7-71]; p0,001), S wave variation (22,3[9,6-31,9] vs 4,8 [2-8]; p0,001) and ΔS wave amplitude (1.1[0.5-1.5] vs 0.2[0.1-0.5]; p0.001) were significantly associated with APE, but no relationship was detected with respect to the presence of atrial arrhythmias, clockwise rotation of the horizontal axis, fragmentation, ST segment deviation, T wave inversion, and S1Q3T3 and S1S2S3 patterns. The percentage of S wave variation (OR: 1072 per 1% increase, 95% CI:1011-1137) was found to be an independent predictor of APE. ΔS wave amplitude0.5mm predicted APE with a sensitivity of 72.6% and a specificity of 74.6% (AUC:0.805, 95% CI: 0.717-0.876; p0.001).The present study demonstrated that QRS and S wave variation could be useful electrocardiographic signs for the diagnosis of APE.

Given that parameters used in the calculation of the PRECISE-DAPT risk score are important contributors to contrast-induced nephropathy (CIN) development, we hypothesized that the PRECISE-DAPT risk score would show good accuracy for predicting CIN in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Therefore, in this study, we aimed to determine the predictive value of the admission PRECISE-DAPT score for the occurrence of CIN in patients with STEMI treated with primary PCI. After evaluation regarding with exclusion criteria, 1280 patients were, respectively, enrolled in the study. The primary end-point was the incidence of CIN. The PRECISE-DAPT score of CIN group was higher than the non-CIN group [31 (24–41) vs. 14 (9–23), p

Background: Even though the relationship between syntax score (SS) and fragmented QRS (fQRS) has been studied, the relation between syntax score II (SS II) and fQRS in patients with ST elevation myocardial infarction (STEMI) is undefined. We aimed to define the relationship between fQRS and SS II for the evaluation of extension and complexity of coronary artery disease. Material and methods: This study enrolled 167 patients undergoing primary percutaneous coronary intervention (pPCI) for STEMI. The standard 12-lead electrocardiograms (ECGs) were obtained from all patients before and after PCI. SS and SS II were calculated in all patients. Transthoracic echocardiography was performed to all patients. Results: Thirty-nine patients (23.4%) had fQRS on their ECGs. The median SS II was 27 (22.9–33.9). SS II values in the fQRS(+) group were statistically significantly higher than that of the fQRS(?) group (35.2 (26.4–47.2) vs. 25.7 (22.1–30.7), p < 0.001). Also, in patients with higher SS II, there was significantly higher number of ECG derivations with fQRS. Conclusions: The presence of fQRS and high number of derivations with fQRS on ECG may be associated with high SS II in patients undergoing pPCI for STEMI. © 2018 Elsevier Inc.

Serum uric acid (SUA) level was shown in various studies to be related to the presence of coronary artery disease and subsequent cardiovascular events. The aim of the present study was to evaluate the association of SUA with SYNTAX score II (SSII) and the long-term prognosis of patients with stable angina pectoris who underwent percutaneous revascularization due to multivessel disease (MVD) and/or unprotected left main disease (UPLMD). Two-hundred and ninety patients with MVD and/or UPLMD who were treated consecutively with percutaneous coronary intervention (PCI) were included in the present study. The study population was divided into high SSII (n: 145; SSII > 32.9) and low SSII (n: 145; SSII ≤ 32.9) according to the median SSII value. The SUA value was significantly higher in the high SSII group than in the low SSII group (5.53 ± 1.95 vs. 6.07 ± 1.88; p = 0.001) and was found to be an independent predictor of high SSII (OR 1.306; 95% CI 1.119–1.525; p = 0,001). Twenty-eight patients (9.7%) died during the long-term follow-up, and SUA and SSII were additionally found to be independent predictors of long-term mortality (HR 1.245, 95% CI 1.046–1.482, p = 0.014; HR 1.042, 95% CI 1.007–1.079, p = 0.018, respectively). In the present study, SUA level was demonstrated to be associated with high SSII and long-term mortality in patients with MVD and/or UPLMD who were treated with PCI.

Introduction:Althoughit has been established that high-degree atrioventricular block (HAVB) isassociated with mortality in the course of ST segment elevation myocardialinfarction (STEMI), the mechanisms by which this AV block cause mortality arenot yet fully understood. In this study we aimed: (i) to investigate therelationship between HAVB and no-reflow, which has been repeatedly shown to beassociated with both short- and long-term mortality; (ii) to determine theeffect of both HAVB and no-reflow on in-hospital and long-term mortality.Patientsand Methods: A total of 1.217 patients who underwent primarypercutaneous coronary intervention (pPCI) were divided into two groups,according to HAVB development, and were further divided according to no-reflowdevelopment. Independent predictors of no-reflow were investigated.Furthermore, patients were compared in terms of in-hospital and long-termmortality. Results: In thepresent study, 47 patients (3.8%) suffered from HAVB and 150 patients (12.3%)had no-reflow. HAVB was an independent predictor of no-reflow [odds ratio (OR):3.127, 95% confidence interval (CI): 1.215-9.056; p= 0.006]. In survivalanalysis, both HAVB and no-reflow were associated with in-hospital (19.1% vs.3.2%; p< 0.001 and 10.7% vs. 2.9%; p< 0.001, respectively) and long-term(15.7% vs. 6.2%; p= 0.037 and 14.1% vs. 5.5%; p< 0.001, respectively)mortality.Conclusion: To our knowledge, this isthe first study in the literature to examine the effect of HAVB on reperfusionsuccess. In this study, we found that HAVB emerged with STEMI isassociated with long-term mortality and to short-term mortality. Also HAVB wasan independent predictor of no-reflow, and patients who had no-reflow had aworse prognosis both in short- and long-term follow-up., Giriş: ST segment yükselmeli miyokart infarktüsü (STEMİ) seyrinde yüksek dereceliatriyoventriküler bloğun (HAVB) mortalite ile ilişkili olduğu tespit edilmişolsa da AV bloğunun mortaliteye hangi mekanizmalarla neden olduğu, net olarakortaya konulmamıştır. Bu çalışmada, (i) HAVB ile hem kısa hem de uzun dönemmortalite ile ilişkili olduğu defalarca gösterilen no-reflow arasındakiilişkiyi (ii) hem HAVB hem de no-reflow’un hastane içi ve uzun dönemmortaliteye etkisini araştırmayı amaçladık.Hastalar veYöntem: Primer perkütan koroner girişim (pPCI) yapılan toplam1217 hasta, HAVB gelişip gelişmemesine, daha sonra da no-reflow gelişipgelişmemesine göre iki gruba ayrıldı. No-reflow’un bağımsız prediktörleriaraştırıldı. Son olarak da hastalar, hastane içi ve uzun dönem mortaliteaçısından karşılaştırıldı.Bulgular: Bu çalışmada, 47 (%3.8) hastada HAVB, 150 (%12.3) hastada no-reflowizlendi. HAVB, no-reflow’un bağımsız bir prediktörü olarak saptandı (OR: 3.127,%95 CI: 1.215-9.056; p= 0.006). Sağkalım analizinde HAVB ve no-reflow’dahastane içi mortalite (sırasıyla %19.1’e karşı %3.2; p< 0.001 ve %10.7’yekarşı %2.9; p< 0.001) ve uzun dönem mortalite (sırasıyla %15.7’ye karşı%6.2; p= 0.037 ve %14.1’e karşı %5.5; p< 0.001) daha yüksek olarak izlendi.Sonuç: Bu çalışmada, STEMİ ileortaya çıkan HAVB’nin, kısa döneme ek olarak, uzun dönem mortalite ile deilişkili olduğu tespit edildi. HAVB ile sağkalımla ileri derecede korelasyonuolan reperfüzyon başarısının ilişkisini gösteren bu ilk çalışmada, HAVB’ninno-reflow için bağımsız bir prediktör olduğunu ve no-reflow’u olan hastalarınhem kısa hem de uzun dönem izlemlerinde kötü prognoza sahip olduğunu ortayakoyduk.

To evaluate left atrial (LA) deformation parameters strain (S)/strain rate (SR) and time to peak S/SR obtained by two-dimensional speckle tracking echocardiography (2D-STE) in patients with hypertension for three LA mechanical phases and to compare them with the same indices in the control subjects.Fifty-five patients with hypertension (HT) and 29 healthy controls were included in the study. All patients had normal LA poster-anterior diameter, LA and left ventricular ejection fractions (LVEF50%) in two-dimensional echocardiography (2-DE). The peak S/SR values (PS/PSR), the time to peak S/SR (TPS/TPSR) were measured using the 12-segment model for the left atrium during contractile (CP) reservoir (RP) and conduit period (COP) of the LA cycle.For two periods (RP and COP), all of the PS and PSR values were significantly lower in hypertensive patients with preserved LAEF and LVEF compared to those in the controls, except for the CP. Similarly, hypertensive patients had significantly higher TPS and TPSR than those in the controls for the RP and COP in the LA wall, except for the CP.LA mechanical function was impaired in hypertensive patients with preserved LA and LV ejection fraction compared to the controls. Although the PS and PSR were decreased for the RP and COP of LA mechanical phases, the TPS/TPSR were prolonged in the HT patients compared to the controls. This might be additional diagnosis criteria to detect the LA myocardial dysfunction and might be a predisposing factor for atrial arrhythmia formation in the hypertensive patients.

Prosthetic valve thrombosis (PVT) is a potentially life-threatening complication associated with high morbidity and mortality. The CHA2DS2-VASc is a clinical score used to determine thromboembolism risk in non-valvular atrial fibrillation patients. Therefore; in this study, we aimed to determine predictive value of the CHA2DS2-VASc score for development of PVT in patients with mechanical prosthetic valve. This was a retrospective study included 417 consecutive patients with mechanic prosthetic valve in whom transesophageal echocardiography (TEE) was performed due to different clinical indications from January 2004 to June 2016. After evaluation according to exclusion criteria, 267 patients with mechanic prosthetic valve were enrolled in the study. The definitive diagnosis of the PVT was made as proposed by TEE finding. The study population was divided into two groups; PVT patients (154 patients) and control group (113 patients) with functional prosthetic valve. The CHA2DS2-VASc score was calculated for each patient from the hospital electronic database. The mechanical mitral valve thrombosis predictive value of variables including CHA2DS2-VASc score was tested in our study. The mean CHA2DS2-VASc score was significantly higher in PVT patients compared to control patients (2.51 ± 1.54 vs. 1.13 ± 1.21, p

The symptoms of aortic dissection (AD) may be highly variable and may mimic other much common conditions. Thus, a high index of suspicion should be maintaned, especially when the risk factors for AD are present or signs and symptoms suggest this possibility. However, sometimes AD may be asymptomatic or progression may be subclinical. Various electrocardiographical (ECG) changes may be seen in AD patients such as ST segment elevation in aVR as well as ST segment depression and T-wave inversion. In this case report, we reported a patient with acute AD whose ECG revealed ST segment elevation in aVR lead in addition to diffuse ST segment depression in other leads. © 2018 The Author(s) 2-s2.0-85064706955

The association of coronary artery disease (CAD) severity with increased C-reactive protein (CRP) and decreased albumin levels has been reported. However, to our knowledge, no study has investigated the usefulness of the CRP to albumin ratio (CAR) in predicting intermediate–high SYNergy between Percutaneous Coronary Intervention with TAXus and cardiac surgery (SYNTAX) score (SS) and high SS II. Consecutive patients (n = 344) treated with percutaneous coronary intervention comprised the study population. The study population was divided into 2 groups according to SS >22 and mean SS II values, respectively. Patients with intermediate–high SS and high SS II had higher CAR than patients with low SS and SS II. History of diabetes mellitus, decreased albumin, lower left ventricular ejection fraction, and elevated CAR (odds ratio [OR]: 1.020; 95% confidence interval [CI], 1.009-1.031; P < .001) were independent predictors of high SS. The presence of hypertension, decreased hemoglobin and albumin levels, and increased CAR (OR: 1.014; 95% CI, 1.004-1.023; P < .001) were independent predictors of SS II. In receiver operating characteristic curve comparison, CAR was superior to CRP and albumin in prediction of intermediate–high SS, but only CRP in prediction of high SS II. The CAR calculated from the admission blood samples could be a useful parameter for predicting CAD severity using SS and SS II.

PubMed: 28623012 Objectives Coronary no-reflow (NR) following primary percutaneous coronary intervention (pPCI) is associated with worsened prognosis in patients with ST segment elevation myocardial infarction (STEMI). Despite rapid developments in cardiovascular area; there are limited data regarding prediction of NR before pPCI. P wave duration and dispersion (PWD, PWDIS respectively) have been studied in STEMI patients and found to be associated with reperfusion success; however none of them has been found to predict NR before PCI. In our study we aimed to evaluate whether PWD, PWDIS and a novel parameter P wave peak time (PWPT) could predict NR development in STEMI patients. Method Fifty six patients who were admitted with anterior STEMI constituted study populations. The diagnosis and treatment of STEMI was made on the basis of current guidelines. P wave parameters including PWD, PWDIS and PWPT were calculated from electrocardiograms that were obtained on admission and 60 min after pPCI. Results Patients were divided into two groups according to the development of NR. We observed that PWPT that were obtained from D2 (PWPTD2) and V1 (PWPTV1) leads were longer in NR group than reflow group. There were significant correlations between PWPT and reperfusion parameters regarding percent of ST segment resolution, peak CKMB level and TIMI frame count of infarct related artery. Preprocedural PWPTD2 was found to be an independent predictor of NR development. Conclusion In our study we observed that PWPT could be a useful parameter in the assessment of reperfusion success and prediction of NR development. © 2017 Elsevier Inc.

We have read with a great pleasure the letter of Yue J, et al. to the editor about our recent study which showed an association between atherogenic index of plasma and no-reflow in patients with ST segment elevation myocardial infarction who underwent primary percutaneous coronary intervention. Yue J, et al. raises concerns about the timing of blood collection, whether if it was taken before the emergency intervention or after. In emergency department, while performing intravenous line, the blood samples for blood biochemistry and whole blood count were also taken from the patients. Another concern of the author was the timing of left ventricular ejection fraction measurement (LVEF). LVEF measurements were obtained before the emergency intervention and some were after the intervention, but before the patient discharge. In our study we included the LVEF in our model, because we could not ignore that modeling which was comprehensively used in recent studies on relation of LVEF and no-reflow. We designed this statistical model not only for the no-reflow prediction but also for the explanation of the no-reflow pathophysiology. We thank the authors' letter for pointing out these issues that we hope to have addressed.

We have read with a great pleasure the letter of Dr. Cure et al. to the editor about our recent study which showed an association between atherogenic index of plasma (AIP) and no-reflow in patients with ST segment elevation myocardial infarction who underwent primary percutaneous coronary intervention. Dr Cure raises concerns about the miscalculation of AIP value that suggested choosing 'mmol/l' in equation instead of 'mg/dl'. As the AIP is the logarithmic transformation of triglyceride/high density lipoprotein; 'mmol/l' and an alternatively 'mg/dl' units can be used in the equation to calculate AIP values. Cure et al. also argue that our patients' lipoprotein levels were lower than expected. However, in a population based study and in several studies which were held in Turkey, the mean values of lipoprotein levels in Turkish population were nearly similar with our study population findings. We thank the authors' letter for pointing out these issues which we hope to have addressed.

A 60-year-old man with metastatic lung cancer presented to the emergency department with severe respiratory distress. He was intubated and admitted to e intensive care unit (ICU). Electrocardiograp...

INTRODUCTION AND OBJECTIVES The aim of this study was to investigate the association of serum albumin (SA) level with long-term prognosis in patients with acute pulmonary embolism (PE). MATERIALS AND METHODS We retrospectively enrolled 269 patients with acute PE. The SA level was obtained within 12-24 hours following admission. The primary endpoints were the incidence of short- and long-term mortality in acute PE patients. The mean duration of the study follow-up was 21 ± 19 months. RESULTS During the follow-up period, short- and long-term mortality rates were higher in patients who had low SA level compared to those who did not have. In multivariate Cox regression analysis, the SA level was found to be independently associated with long-term mortality (HR: 0.47, 95%CI: 0.28-0.78, P = 0.004). In receiver operating characteristics analysis, the SA level of ≤3.17 predicted long-term mortality with a sensitivity of 77.5% and a specificity of 79.5% (area under the curve 0.82, 95%CI: 0.76-0.87, P

Kounis syndrome or allergic angina is defined as the coincidental occurrence of chest pain and allergic reactions accompanied by clinical and laboratory findings of classical angina pectoris. It is triggered by the action of potent vasoactive and inflammatory mediators, which are released from the mast cells during the allergic reaction. Epinephrine is a life-saving medication in anaphylaxis; however, it can aggravate ischemia and induce coronary vasospasm and arrhythmias. Here, we present a patient with Kounis syndrome that was caused by intramuscular injection of procaine penicillin G, and in whom epinephrine administration for treatment of laryngeal edema had provoked severe myocardial ischemia.