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OBJECTIVE In daily clinical practice, we encounter ST segment elevation myocardial infarction (STEMI) patients loaded with clopidogrel upon admission to primary angioplasty. These patients are loaded with ticagrelor, if there is no contraindication. This study aimed to compare the level of injury between STEMI patients who were first loaded with clopidogrel and the ones first loaded with ticagrelor. Although patients were switched from clopidogrel to ticagrelor at the first hour of angioplasty, antiplatelet action may still be lower than the others. METHODS This study included STEMI patients with angina onset of ≤3 h and who had primary angioplasty to proximal segment of one coronary artery. All patients had total thrombotic occlusion at the proximal segment. Δtroponin level (6th-hour troponin-admission troponin) was calculated to compare the level of myocardial injury. RESULTS A total of 105 patients were included; 52 were loaded with ticagrelor and 53 with clopidogrel first and switched to ticagrelor. Baseline characteristics were similar in the two groups, except from type B2 lesions being more common in the ticagrelor-loaded group. Δtroponin levels were significantly higher in the clopidogrel-loaded group compared with the ticagrelor-loaded group (p=0.013). Major bleeding and in-hospital MACE rates were similar in both groups. CONCLUSION In STEMI patients, the degree of troponin rise was more prominent in clopidogrel-loaded patients, despite the switch to ticagrelor in the first hour of intervention. Clopidogrel is slow and modest, and variable platelet inhibition may continue to be a negative factor for protection from myocardial injury, even after switching to ticagrelor.

Elective percutaneous coronary intervention (ePCI) may cause minor elevation of cardiac enzymes, so-called minor myocardial injury (MMI) which can be due to different pathophysiological mechanism (e.g. distal embolisation, side branch occlusion, increased platelet activation triggered by the intracoronary metallic stents). We aimed to compare the effectiveness of ticagrelor versus clopidogrel for the prevention of MMI and major adverse clinical events (MACEs) after ePCI.Study population consisted of two groups of patients based on the treatment: Group I, receiving clopidogrel (n = 104), Group II, receiving ticagrelor (n = 96). Cardiac troponin I (cTnI), CK-MB were studied before and 12 hours after the procedure. Elevation of cTnI greater than 0.06 ng/ml was considered as MMI. All patients were also evaluated for the MACEs (death, myocardial infarction, stroke and transient ischaemic attack).Fifty-two of 200 patients (26%) had MMI after the procedure. The minor myocardial injury was significantly more prevalent in clopidogrel group than that of ticagrelor group (33% vs. 19%, p = .03). Myocardial infarction (MI) and MACEs were significantly higher in the clopidogrel group (15% vs. 6%, for MI, p = .04; 16% vs. 6%, for MACEs, p = .03, respectively). Multivariate analysis demonstrated antiplatelet treatment, saphenous graft intervention, type-C lesion as independent predictors of MMI.Present study showed that the combination of ticagrelor and aspirin was more effective than combination of clopidogrel and aspirin in decreasing MMI and MACEs after elective stenting.

Coronary artery aneurysm/ectasia (CAE) is defined as a dilatation of a coronary artery segment to more than 1.5-fold normal size in diameter. The leading etiologic factor of CAE is atherosclerotic coronary artery disease, but it can be seen rarely secondary to inflammatory diseases in romatological diseases (e.g. Kawasaki disease, Takayasu’s arteritis, Systemic Lupus Erythematosus (SLE), rheumatoid arthritis). We present here in a giant coronary aneurysm, possible etiologic causes and treatment in a patient with SLE who had a previous coronary intervention. Treatment was performed successfully with a covered stent. We thought that the aneurysm was developed secondary to the drug eluting stent that was previously implanted while SLE was in remission. This case report emphasizes that coronary artery disease should be considered in SLE patients who do not have traditional risk factors for coronary artery disease.

Isolated coronary artery ectasia (CAE) may be associated with stable or unstable coronary events despite the absence of epicardial coronary stenosis. Impaired coronary flow dynamics and myocardial perfusion have been demonstrated in stable patients with ectatic coronary arteries. We aimed to assess whether epicardial flow and tissue-level perfusion would be improved by diltiazem in myocardial regions subtended by the ectatic coronary arteries in patients with isolated CAE. A total of 60 patients with isolated CAE were identified of 9,780 patients who underwent elective coronary angiography. Patients were randomized to 5 mg of intracoronary diltiazem or saline. Coronary blood flow of the microvascular network was assessed using myocardial blush grade (MBG) technique. The thrombolysis in myocardial infarction (TIMI) flow grade and TIMI frame count (TFC) were used to assess epicardial coronary flow. MBG (from 2.4 to 2.6, p = 0.02), TIMI flow grades (from 2.4 to 2.8, p

Whether there is any particular role of hypertension in remodeling process has not been completely understood yet. The aim of this study was to assess the association between hypertension and remodeling patterns in normal or minimally atherosclerotic coronary arteries. Seventy-nine patients who were free of significant coronary atherosclerosis were divided into two groups according to the absence (n = 39) or presence (n = 40) of hypertension; and standard intravascular ultrasound examination was performed in 145 segments. To determine the remodeling pattern in early atherosclerotic process, patients were also analyzed according to the level of plaque burden at the lesion site after the analysis of remodeling patterns. Positive remodeling was more prevalent in the hypertensive group (52.5% vs. 12.8%; P.001) whereas negative remodeling was more common in diabetic patients (53.6% vs. 27.4%; P = .03). Mean remodeling index was 1.04 for hypertensives and 0.96 for normotensives (P = .03). There were no correlations between remodeling patterns and other risk factors such as age, family history, and hypercholesterolemia. Early atherosclerotic lesions (30%) exhibited more negative remodeling characteristics while intermediate pattern was observed more frequently in patients with high plaque burden (P = .006 and .02, respectively). Positive remodeling showed no association in this context (P = .07). This study demonstrated that minimal atherosclerotic lesions in hypertensives had a tendency for compensatory arterial enlargement. Positive remodeling may result from local adaptive processes within vessel wall or hemodynamic effects of blood pressure itself.

Background The aim of the study is to evaluate the association of inflammatory markers with endothelial function in syndrome X. Methods The study population consisted of 59 prospectively enrolled patients (28 women and 31 men; mean age, 50.29 +/- 6.48 years) and 51 healty control subjects (18 women and 33 men; mean age, 51.04 +/- 7.25 years). High-sensitive CRP (hs-CRP), white blood cell (WBC) count and its subtypes [neutrophil (N), lymphocyte (L) and monocyte (M)] were measured in each subject. Endothelial function was assessed with the brachial artery flow-mediated dilatation (FMD) technique. Results WBC counts and hs-CRP levels were significantly higher in patients who had syndrome X than in control subjects (7.53 +/- 1.52 x 10(9) cells/L versus 6.21 +/- 1.17 x 10(9) cells/L, P = 0.0001, and 3.11 +/- 0.63 mg/L versus 2.68 +/- 0.76 mg/L, P = 0.002, respectively). Neutrophil count and N/L ratio was significantly increased in syndrome X when compared with the control subjects (5.14 +/- 1.10 x 10(9) cells/L versus 4.11 +/- 0.76 x 10(9) cells/L, P = 0.0001 and 2.75 +/- 1.06 versus 2.37 +/- 0.65, P = 0.02, repectively). Other subtype counts were similar between the groups. FMD was impaired significantly in patients who had syndrome X in comparison with the control subjects (5.71 +/- 4.08% versus 16.02 +/- 4.13%, P = 0.0001). There was a significant correlation between hs-CRP levels and FMD measurements (r = -0.44; P = 0.0001). Furthermore, the correlation between WBC count and FMD measurements were also significant (r = -0.48; P = 0.0001). Conclusions The present study showed that hs-CRP and WBC count were higher in patients with syndrome X than in control subjects. Furthermore, endothelial function was impaired significantly in patients with syndrome X.The increased levels of hs-CRP and WBC count may suggest that these markers may be used in clinical practice for the assessment of the inflammatory status of the endothelium in syndrome X.

Background: Keloid and hypertrophic scars are two types of proliferative scars at sites of cutaneous injury that form as a result of an abnormal wound-healing process. Proliferative scar formation after skin injury and restenosis after coronary stenting have common features. The aim of this study was to investigate the association of proliferative scars with coronary stent restenosis. Methods: Patients with previous open heart surgery with median sternotomy who had coronary stenting after the surgery and were admitted for control angiography were included in the study. The patients were divided into two groups according to the presence or absence of proliferative scars. The primary end point was the incidence of angiographic restenosis in patient groups. Results: The study group consisted of 80 patients (64 men; mean age 64 ± 9 years). Twenty-three patients (29%) have a proliferative scar. In general, two groups were comparable with regard to baseline lipid profiles, demographics, and cardiovascular risk factors. Restenosis was significantly more prevalent in patients with proliferative scars than with controls ( p = .04). By multivariate logistic regression analysis, stent length (odds ratio [OR] 1.12, p = .005), diabetes (OR 3.3, p = .03), and proliferative scar (OR 4.2, p = .02) independently predicted in-stent restenosis. Conclusion: The findings of this study suggest that patients with proliferative scars may have a higher risk of in-stent restenosis.

The authors undertook this study to see whether highly developed coronary collaterals at an area shed by a totally occluded coronary artery predicts myocardial viability. Percutaneous coronary intervention (PCI) of a totally occluded coronary artery has been debated since its introduction. It is recommended to search for viable myocardium before opening a totally occluded coronary artery; however, there is no practical yet sensitive method of assessing myocardial viability in the catheterization laboratory. Forty-seven consecutive patients (12 women, 25.5%; 35 men, 74.5%), each with 1 totally occluded coronary artery, were prospectively enrolled to the study. After the diagnostic coronary angiography, all patients underwent dobutamine stress echocardiography to determine viable myocardium at the territory of the totally occluded coronary artery, and the status of angiographic coronary collaterals was assessed. Patients were then divided into 2 groups according to the presence (Group A) or absence (Group B) of viable myocardium by stress echocardiography. Eighteen patients (38.3%) had viable myocardium (Group A) in the area shed by the totally occluded coronary artery and 29 patients (61.7%) had nonviable myocardium (Group B). The incidences of significant coronary collateral circulation to the viable (Group A) and nonviable (Group B) areas were 66.7% (12 patients) and 20.7% (6 patients), respectively (p = 0.002). Logistic regression analysis was used to evaluate the independent factors for viable myocardium, and only significant coronary collateral circulation was found to be an independent factor for the detection of viable myocardium (p = 0.006, OR 16.7, 95% CI 2.25 to 124.4). The sensitivity and specificity of good collateral circulation for the detection of viable myocardium were 75% and 65.7%, respectively. The positive predictive and negative predictive values of the good coronary collateral circulation in detecting viable myocardium were 75% and 79%, respectively. The authors conclude that good coronary collaterals have a high sensitivity and positive predictive value for the prediction of viability as shown by dobutamine echocardiography, and only by assessing the coronary collateral circulation can one decide for percutaneous coronary revascularization, if not for coronary artery bypass surgery.

Recent studies have documented that elevation of C-reactive protein (CRP) levels after percutaneous coronary intervention (PCI) have been predictive of adverse outcome. This study was performed to test the hypothesis that preprocedural use of naproxen sodium is associated with a reduction in the extent of inflammatory response and myocardial injury after PCI.Ninety-seven patients who were scheduled for elective PCI were randomized either for naproxen sodium (500 mg bid) (n:39, 75% male, 59+/-10 years) or control (n:58, 76% male, 60+/-10 years). All patients were troponin negative before the procedure. Blood samples for CRP, Troponin I and CK-MB were collected at baseline and after the procedure.The characteristics were similar between the two groups. After coronary stenting, the rise in CRP levels was significantly higher in controls than those treated with naproxen (DeltaCRP=6.4 mg/L in the controls and 0.43 mg/L in the naproxen group, p0.0001). The incidence of any troponin I elevation or CK-MB elevation above upper limit of normal was not statistically different between groups. During follow up (12+/-2 months), major cardiac adverse events (death, myocardial infarction, and revascularization of target lesion) was similar between groups.Our data show that naproxen pretreatment leads to significant suppression in PCI related CRP elevation. However this improvement in CRP levels was not associated with any significant reduction in post-PCI myonecrosis.

We searched a randomized, double-blinded, prospective study that compared the effectiveness of clopidogrel versus ticlopidine for prevention of minor myocardial injury (MMI) and major clinical events (MCEs) after elective coronary stenting. A total of 158 consecutive patients (98 male, 60 female patients with a mean age of 59.3+/-5.4 years) were divided into two arms based on treatment with thienopyridines: group I, clopidogrel 1 x 300 mg as a loading dose, and 1 x 75 mg per day thereafter, group II, ticlopidine 2 x 250 mg daily. Both thienopyridines were started on the same day as stent placement. Cardiac troponin T (cTnT) was measured immediately before and 12 h after the procedures. All patients were followed-up during the hospital stay (6+/-2 days) with respect to MMI and MCEs. The increase frequency and the amount of cTnT level in group I was found significantly lower compared with group II (5 vs.15; P0.01; 0.38+/-0.11 vs. 0.44+/-0.12 ng/ml; P0.001, respectively). Patients with elevated cTnT levels more likely to have C type lesion (P0.004). Though there was a trend toward increased major clinical events rate in group II than those of group I, the statistical difference was not different (4 vs. 1.3%; P0.05). The present study showed that the combination of clopidogrel and aspirin was more effective than the combination of ticlopidine and aspirin in decreasing the rate of MMI.

The aim of the study was to determine whether ticlopidine treatment prior the coronary stenting would be associated with lower rates of procedure-related minor myocardial injury (MMI) in patients undergoing elective coronary stenting. In this retrospective, nonrandomized, uncontrolled study, a total of 153 consecutive patients with a mean age of 63.4+/-8.9 years were divided into two groups based on the duration of ticlopidine treatment: group I (n=81), ticlopidine/=3 days before the procedure, group II (n=72), on the same day as stent placement. Cardiac troponin T (cTnT) was measured immediately before and 12 h after the procedures. All patients were followed-up during the hospital stay with respect to MMI and major clinical events (MCE). The increase frequency and the amount of cTnT level in group I was found to be significantly lower compared with group II (4 vs. 13; P0.01, and 0.35+/-0.06 vs. 0.52+/-0.11 ng/ml; P0.01, respectively). In general, patients with elevated cTnT levels are more likely to have C type lesion and multivessel procedure than those of normal cTnT level (41 vs.10%; P0.002 and 47 vs. 17%; P0.009, respectively). Though there was a trend toward increased MCE rates in group II than that of group I, this did not reached statistical significance (3 vs.1; P=NS). The present study shows that an anti-platelet treatment with ticlopidine prior the coronary stenting of adequate duration to allow for the development of maximal inhibition is associated with a markedly decreased incidence of procedure-related MMI. Therefore, ticlopidine pretreatment may be a cost alternative for the prevention of platelet-rich microembolism in patients undergoing elective coronary stenting.

Coronary artery fistula constitutes a rare congenital anomaly. The reported incidence of this anomaly ranges from 0.1% to 0.2% of the population undergoing coronary angiography. Coronary-pulmonary artery fistula is an extremely rare congenital anomaly of the coronary artery. Its real incidence is unknown. The authors report a case of coronary-pulmonary artery fistula that caused right heart failure in a 77-year-old woman. The fistula, arising from a proximal portion of the circumflex artery to the pulmonary artery, was sealed successfully using a Jostent (polytetrafluoroethylene-covered graft stent).

Mitral inflow velocities are widely used for the evaluation of left ventricular (LV) diastolic function. However, they are closely affected by other factors such as preload. The purpose of this study was to evaluate the usefulness of tissue Doppler velocities obtained from the mitral annulus for the evaluation of ventricular relaxation in patients under different loading conditions. We also evaluated the effect of preload at different sides on the mitral annulus. The study population consisted of 62 consecutive patients (38 male, 24 female with a mean age of 42 ± 13 years) who have undergone hemodialysis. Both mitral inflow velocities (E wave, A wave, E wave deceleration time and isovolumetric relaxation time) and mitral annulus tissue Doppler velocities (E′, A′) from the septal, lateral, anterior, posterolateral and inferior sides of the mitral annulus were measured immediately before and after hemodialysis. Mitral inflow E and A wave velocities and E/A ratio decreased significantly (p 0.05 for all) after hemodialysis. The decrease in E wave and E/A ratio in mitral inflow measurements and E′ velocities and E′/A′ ratios in tissue Doppler measurements were correlated with the amount of fluid extracted (for mitral inflow E wave, r = 0.392, p = 0.002 and E/A ratio, r = 0.280 and p = 0.027; for lateral side E′, r = 0.329, p = 0.009 and E′/A′ ratio, r = 0.286, p = 0.04; for septal side E′, r = 0.376, p = 0.003 and E′/A′ ratio, r = 0.297, p = 0.019; for anterior side E′, r = 0.342, p = 0.007 and E′/A′ ratio, r = 0.268, p = 0.035; for posterolateral side E′, r = 0.423, p = 0.001 and E′/A′ ratio, r = 0.343, p = 0.007; and for inferior side E′, r = 0.326, p = 0.01 and E′/A′ ratio, r = 0.278, p = 0.029). We conclude that mitral annular velocities obtained by tissue Doppler are preload dependent parameters for the evaluation of LV diastolic function.

Textiloma (gossypiboma), a retained surgical sponge or gauze, is a rare though important complication of cardiac surgery. It may cause heart failure, chronic chest pain, abscess formation or fistulas. As a result of non-specific clinical and radiological presentations, and medicolegal issues, this diagnosis is usually overlooked. A 60-year-old male patient was admitted with complaints of exertional dyspnea, chest pain, and cough, ongoing for nearly 4 months. His medical history included atrial fibrillation, an ischemic cerebrovascular accident and a coronary artery by-pass operation for three-vessel disease 15 years previously. Physical examination revealed jugular venous distention, irregular heart rate with Levine grade 4 pansystolic murmur at the apex, and inspiratory crackles at the middle and basal fields of the right lung, hepatomegaly and +1 pitting pretibial edema. His electrocardiogram was consistent with atrial fibrillation with rapid ventricular response. A chest X-ray revealed a rightsided pleural effusion (Figure A). A transthoracic echocardiography showed severe tricuspid and mitral regurgitation, bi-atrial dilatation and leftventricular hypertrophy. After intravenous diuretic therapy, a control chest X-ray was obtained to show regression of the effusion, and revealed a suspicious mass at the right heart border (Figure B). A transesophageal echocardiography was performed, and a left atrial thrombus, and a mass lesion with diameters of 46 mm × 43 mm compressing the right atrium were seen (Figure C, Video 1*). Multi-sliced computed tomography showed a mass consistent with textiloma, measuring 6.4cm × 4.7cm, compressing the right atrium and a right-sided pleural effusion (Figure D). After the diagnosis of textiloma had been made, the patient underwent re-do cardiac surgery for mass removal. Median Sternotomy revealed a textiloma behind the right atrium, which was non-capsulated and hard. Following an uneventful postoperative period, he was discharged. A clinic visit 1 month later showed him to be in good condition. 686

Objective: This study aims to show the effect of myeloperoxidase (MPO), hsCRP, TNF-alpha values and leukocyte count on the development of coronary collateral arteries in patients with severely diseased coronary arteries. Methods: Current study is an observational cross-sectional study. In the study, 295 patients who had functional obstruction or total coronary occlusion at least 1 month on their angiograms were included. We divided the study population into two groups according to their collateral grade as good collateral (Group 1) (169 patients) and poor collateral (Group 2) (126 patients). Multiple logistic regression analysis was used for independent variables associated with the coronary collateral grade. Results: History of stable angina pectoris was statistically more prevalent in good collateral group (61.5% and 48.4%, p=0.025). Furthermore, MPO activation was higher in good collateral group and the difference was statistically significant (3.7 U/mL and 3.0 U/mL p=0.001). In multiple logistic regression analysis, stable angina pectoris [OR 1.7, 95% CI (1.05-2.8), p=0.03] and high MPO levels [OR 2.7, 95% CI (1.7-4.3), p

The authors report a case of myocardial bridging associated with nonobstructive hypertrophic cardiomyopathy and severe intractable chest pain that was relieved by surgical resection of the muscular bridge. Surgical resection of a myocardial bridge may be considered in patients with refractory symptoms that can clearly be attributed to muscular bridge.

BACKGROUND Calcium phosphate deposition is present even in the early phases of the atherosclerotic plaque formation. Calcifying nanoparticles (CNPs), previously known as nanobacteria, have emerged as a potential causative agent for pathological calcification in human vasculature. This study investigates the relationship between the anti-CNPs antibody titers and the extent of coronary calcification. METHODS A total of 197 consecutive patients undergoing multidetector computed tomography were enrolled in this study. The patients with coronary artery calcification (CAC; n=103) were included in the CAC group, and those without calcification (n=94) were determined as controls. The commercially available enzyme-linked immunosorbent assay kits were used to detect IgG antibodies against CNPs in serum samples. RESULTS Mean titers of anti-CNPs antibodies were higher in individuals with CAC than in the control group (0.4 ± 0.4 vs. 0.19 ± 0.21U; P

Lutembacher syndrome is a rare combination of congenital atrial septal defect (ASD) and acquired mitral stenosis (MS). Although it is traditionally corrected by surgical treatment, both conditions are amenable to transcatheter treatment without the need for surgery. We present a 49-year-old woman with Lutembacher syndrome. On pretreatment transthoracic echocardiography, planimetric mitral valve area was 1.5 cm(2), maximum diastolic gradient was 17 mmHg, and mean diastolic gradient was 9 mmHg. Combined percutaneous treatment was performed including balloon valvuloplasty for MS and closure of the ASD with the Amplatzer septal occluder. The patient was discharged uneventfully. Transthoracic echocardiography performed a week later showed planimetric mitral valve area as 2.1 cm(2), maximum diastolic gradient as 9 mmHg, and mean diastolic gradient as 4 mmHg. Complete closure of the ASD was achieved. Transcatheter treatment may be an effective alternative to surgery in selected patients with Lutembacher syndrome.

Background Endothelial dysfunction is thought to be a potential mechanism for the decreased presence of coronary collaterals. The aim of the study was to investigate the association between systemic endothelial function and the extent of coronary collaterals. Methods We investigated the association between endothelial function assessed via flow mediated dilation (FMD) of the brachial artery following reactive hyperemia and the extent of coronary collaterals graded from 0 to 3 according to Rentrop classification in a cohort of 171 consecutive patients who had high grade coronary stenosis or occlusion on their angiograms. Results Mean age was 61 years and 75% were males. Of the 171 patients 88 (51%) had well developed collaterals (grades of 2 or 3) whereas 83 (49%) had impaired collateral development (grades of 0 or 1). Patients with poor collaterals were significantly more likely to have diabetes (p = 0.001), but less likely to have used statins (p = 0.083). FMD measurements were not significantly different among good and poor collateral groups (11.5 ± 5.6 vs. 10.4 ± 6.2% respectively, p = 0.214). Nitroglycerin mediated dilation was also similar (13.4 ± 5.9 vs. 12.8 ± 6.5%, p = 0.521). Conclusion No significant association was found between the extent of angiographically visible coronary collaterals and systemic endothelial function assessed by FMD of the brachial artery.

Purpose To determine whether subcutaneous administration of nitroglycerin mixed with local anesthetic agent results in effective vasodilation of the radial artery, and whether this technique improves access time and decreases complications. Materials and Methods This prospective study consisted of two consecutive investigations. In the first ( n = 30), only local anesthetic agent (prilocaine 2%) was injected into one arm, and local anesthetic agent plus 500 μg nitroglycerin was injected into the other arm. Radial artery diameters before and after injections were measured by ultrasonography. In the second, 33 patients received local anesthetic agent (prilocaine 2%) plus 500 μg nitroglycerin (group A) and 30 received only local anesthetic agent (group B) to determine whether the addition of nitroglycerin would improve radial artery access time, duration of angiography, perception of arterial pulse (ie, pulse score), number of punctures before successful cannulation, and complication rates. Results In the first investigation, radial artery diameter increased significantly in the nitroglycerin-treated arm (2.3 mm ± 0.4 vs 2.9 mm ± 0.5; P = .05). In the second, there were no significant differences between groups with respect to age, sex, duration of angiography, and number of punctures before cannulation. However, the pulse score increased and radial artery access time improved significantly after addition of nitroglycerin (79% vs 10% [ P P = .005], respectively). Radial artery spasm and thrombosis were less frequently observed in group A, albeit to an insignificant extent ( P = .39 and P = .49, respectively). Conclusions Subcutaneous administration of nitroglycerin significantly increased radial artery diameter, which can lead to facilitation of catheterization of the radial artery for arteriography and interventions.

BACKGROUND The aim of this study was to evaluate tissue-level perfusion in patients with idiopathic dilated cardiomyopathy (IDC), using the myocardial blush grade technique. METHOD The study population consisted of 26 prospectively enrolled IDC patients (15 women and 11 men; mean age, 59+/-8.8 years) and 26 control subjects (11 women and 15 men; mean age, 54.9+/-10.6 years), whose angiographic films were technically adequate for myocardial blush grade analysis. After grading, we measured total blush score (TBS) for both groups. TBS was determined as the sum of the blush grades of each coronary territory. RESULTS A total of 156 coronary territories in both groups were assessed. Average of TBS was significantly lower in patients with IDC than in control group (7.6+/-1.2 vs. 8.8+/-0.4; P

Background: Angiotensin II induces various growth factors such as vascular endothelial growth factor, platelet-derived growth factor, and fibroblast growth factor, and recent studies suggest that the expression of these growth factors promotes collateral growth. We hypothesized that the blockage of angiotensin II production by ACE inhibitors might interfere with collateral development in patients with coronary occlusion. Methods: The study group consisted of 187 patients (114 males, mean ages, 62 ± 11 years) who had chronic (> 1 month) coronary occlusion (TIMI flow grade ≤ 1) in one of 3 epicardial coronary arteries. Collaterals were graded using the Rentrop classification, and the patients were divided into 2 groups according to having good (grade 2 and 3) or poor (grade 0 and 1) collaterals (n = 127 and 60, respectively). Clinical and angiographic characteristics were compared in the 2 groups. Results: ACE inhibitor use (52% versus 35%, P = 0.04) and the prevalence of diabetes mellitus (DM) (43% versus 27%, P = 0.02) was higher in patients with poor collaterals. Patients with poor collaterals had a higher frequency of circumflex artery (Cx) occlusion, worse wall motion, and lower ejection fraction. In multivariate analysis, ACE inhibitor use (OR: 2.4; 95% CI = 1.23-4.68, P = 0.01) and the occlusion of Cx (OR: 3.3, 95% CI; 1.33-8.12, P = 0.01) were found to be independent predictors for poor collateral development, whereas there was a trend for DM as a predictor for poor collaterals (OR: 1.9, 95% CI = 0.97-3.8, P = 0.06). Conclusion: The findings suggest that ACE inhibitor therapy may contribute to poor collateral development in patients with coronary occlusion.

To investigate the role of angiotensin-converting enzyme (ACE) gene polymorphism in patients with degenerative aortic valve calcification (AVC).Our study consisted of 305 Turkish patients of European descent (139 male, 166 female; mean plus or minus age, 68 plus or minus 9 years) referred to our echocardiography laboratory for aortic valve evaluation between June 2, 2003, and April 29, 2005. The severity of AVC was graded from 1 to 6 by echocardiography. We used polymerase chain reaction to determine ACE gene polymorphism.The ACE insertion/deletion genotype distributions for the study population were in Hardy-Weinberg equilibrium (chi square equals 3.5, P equals .18). The study population was divided into 3 groups based on the severity of AVC: those with grade 1 calcification were in group 1, those with grades 2 to 4 in group 2, and those with grades 5 to 6 in group 3. Group 1 patients were significantly younger, less likely to have hypertension and diabetes, and had higher high-density lipoprotein cholesterol levels. The genotype frequencies were significantly different among groups, with the insertion/insertion genotype being less prevalent in group 3 patients. In multivariate analysis, independent predictors of severe AVC were hypertension (odds ratio [OR], 5.6; 95% confidence interval [CI], 2.8 to 11.0; P less than .001), low high-density lipoprotein cholesterol (OR, 2.7; 95 percent CI, 1.5 to 4.9; P equals .001), and the deletion/deletion and insertion/deletion vs insertion/insertion genotype (OR, 3.2; 95 percent CI, 1.5 to 7.2; P equals .004).These results suggest that ACE gene polymorphism may be associated with severe AVC.

A 43-year-old man receiving statin monotherapy (10 mg atorvastatin) for hypercholesterolemia had unilateral blepharoptosis as the result of isolated myositis of the levator muscle. Statin-induced myositis in the levator muscle should be considered in the differential diagnosis of acquired unilateral blepharoptosis of unknown cause.

Background In vitro studies have shown that C-reactive protein (CRP) attenuates nitric oxide production and inhibits angiogenesis, which may result in impaired collateral development. The aim of this study was to investigate the association between high sensitivity CRP (hsCRP) levels and the extent of coronary collaterals. Materials and methods We investigated the association between hsCRP levels and the extent of coronary collaterals according to the Rentrop classification in a cohort of 185 patients who had high-grade coronary stenosis or occlusion on their angiograms. Results Mean age was 62 years and 80% were males. Subjects with a higher grade of collaterals were significantly less likely to have diabetes mellitus (OR; 0·48, 95% and CI; 0·28, 0·83) or acute coronary syndrome (OR; 0·58, 95% and CI; 0·33, 0·99), but they were more likely to have higher number of vessels with significant stenosis (OR; 1·41, 95% and CI; 1·03, 1·93) and to have received statins (OR; 1·84, 1.09, 3.13). The mean hsCRP values reduced significantly as the Rentrop grades increased (trend, P = 0·0006). After adjusting for age, gender, statin use, clinical presentation with acute coronary syndrome, diabetes mellitus and the number of vessels with significant stenosis, each 10-unit increase in hsCRP values corresponded to a 31% reduced odds of having a higher collateral score (OR; 0·69, 95% and CI; 0·53, 0·90). Conclusions Our findings indicate that elevated hsCRP levels are associated with a significant impairment in coronary collateralization. These data suggest a previously unrecognized mechanism through which inflammation may worsen cardiovascular outcomes.

A recent ex vivo study suggests that the metabolic activation of clopidogrel is catalyzed by cytochrom P450 (CYP) 3A4 and is competitively inhibited by atorvastatin, but not pravastatin.To determine whether the incidence of procedure-related myocardial injury, assessed by cardiac troponin T (cTnT) release, is altered when clopidogrel is coadministered with a statin that is predominantly CYP3A4-metabolized.Of the 211 consecutive patients who underwent coronary stenting after pretreatment with clopidogrel, 114 were receiving a CYP3A4-metabolized statin (59 simvastatin and 55 atorvastatin, Group 1), and 37 were receiving a non-CYP3A4-metabolized statin (30 pravastatin and 7 fluvastatin, Group 2) whereas 60 patients were not taking any statins (Control). All were troponin-negative before the procedure. The overall incidence of postprocedural cTnT positivity (0.10 ng/ml) was 30.8%. Group 2 patients were less likely to exhibit cTnT rise relative to Group 1 patients (8% versus 41.6%; p = 0.004) and relative to controls (8% versus 32.5%; p0.001). Multivariate analysis identified the use of a non-CYP3A4-metabolized statin before coronary stenting as the sole independent predictor for lower incidence of procedure-related cTnT elevation with estimated Odds ratios of 0.16 relative to no statin therapy (95% CI: 0.04-0.59; p = 0.006) and 0.18 relative to CYP3A4-metabolized statin therapy (95 CI: 0.053-0.637; p = 0.008)Benefit derived from the preprocedural use of pravastatin and fluvastatin but not atorvastatin and simvastatin suggest that the ex vivo finding of a negative interaction when coadministering a CYP3A4-metabolized statin with clopidogrel may be of clinical significance.

We evaluated tissue level perfusion in patients who had syndrome X using the myocardial blush grade technique. Normal tissue perfusion in all coronary territories was observed in 23 patients (41.8%) who had syndrome X and in 44 control subjects (80%). Total myocardial blush score (sum of the myocardial blush grades of each coronary territory) was significantly lower in patients who had syndrome X than in control subjects (8.2 +/- 0.7 vs 8.7 +/- 0.5, p0.0001). We have demonstrated for the first time that a substantial number of patients who have syndrome X have impaired tissue level perfusion, and this might be assumed as a surrogate marker of a diseased microvascular network in the catheterization laboratory.

Effects of ingesting garlic extract on plasma and erythrocyte antioxidant parameters of atherosclerotic patients were investigated in this study. Eleven patients with atherosclerosis participated in the study. They ingested a dose of 1 ml/kg body weight of garlic extract daily for 6 months (study period). Before and after this period, fasting blood samples were obtained, and oxidant (malondialdehyde, MDA and xanthine oxidase, XO) and antioxidant (superoxide dismutase, SOD and glutathione peroxidase, GSH-Px) parameters were studied in plasma and erythrocytes obtained from the patients. Blood samples obtained from 11 healthy subjects served as the controls. Plasma XO activity and MDA levels were higher, but plasma and erythrocyte GSH-Px activities were lower, in patients with atherosclerosis relative to those of the control group. Our results showed that ingestion of garlic extract leads to significantly lowered plasma and erythrocyte MDA levels in the patients even in the absence of changes in antioxidant enzyme activities. Our results also demonstrated the presence of oxidant stress in blood samples from patients with atherosclerosis, but ingesting garlic extract prevented oxidation reactions by eliminating this oxidant stress. Thus, it is possible that reduced peroxidation processes may play a part in some of the beneficial effects of garlic in atherosclerotic diseases.

Coronary artery fistula constitutes a rare congenital anomaly. The reported incidence of this anomaly ranges from 0.1% to 0.2% of the population undergoing coronary angiography. Coronary-pulmonary artery fistula is an extremely rare congenital anomaly of the coronary artery. Its real incidence is unknown. The authors report a case of coronary-pulmonary artery fistula that caused right heart failure in a 77-year-old woman. The fistula, arising from a proximal portion of the circumflex artery to the pulmonary artery, was sealed successfully using a Jostent (polytetrafluoroethylene-covered graft stent).

A single coronary artery (SCA) constitutes a rare congenital anomaly. The reported incidence of SCA ranges from 0.2 1.6% of the population undergoing coronary angiography. The congenital absence of the ostium of the right coronary artery (RCA) with the origin of the RCA as a continuation of the distal circumflex artery is an extremely rare variant of the SCA. Its real incidence is unknown. We report a case of a 38-year-old white female with non-obstructive hypertrophic cardiomyopathy associated with SCA, in which the RCA arises as an extension of the circumflex artery.

This nonrandomized study evaluated the incidence of minor myocardial injury (MMI) in prospectively selected patients with simple lesion morphology and class II stable angina undergoing stenting with or without predilatation.A total of 154 patients were divided into two arms based on the stenting technique used: direct stenting without predilatation (Group I; n = 78) and stenting with predilatation (Group II; n = 76). Cardiac troponin T (cTnT) was measured immediately before, at 12 hours and 24 hours postprocedure. The primary endpoint was the MMI in-hospital. The secondary endpoint of the study was the major clinical event (MCE) rate in-hospital and up to 6 months.The frequency increase in Group I was found to be significantly lower compared with Group II (5.1% vs. 21%, respectively; p0.007), as was the amount of cTnT release (0.28 0.04 vs. 0.51 0.12 ngr/ml at 12 hours, p0.001; 0.28 0.06 vs. 0.51 0.10 ngr/ml at 24 hours, p0.0004). No MCE was seen during the in-hospital period in both groups. Furthermore, no significant differences were found between the 2 groups with respect to MCE (12.8% vs. 18.4%, respectively; p0.05) at 6 months. The balloon inflation time (BIT) was significantly longer in patients with abnormal cTnT level than in those with normal cTnT level in Group II (120.3 4.7 seconds vs. 118.2 1.3 seconds; p0.002) but there wasn t any statistical difference in Group I (32.4 2.1 seconds vs. 30.6 2.4 seconds; p0.05). Furthermore, there was not any statistical difference with respect to the number of balloon inflations in patients with normal and abnormal cTnT levels in either group (1.2 0.2 inflations vs. 1.3 0.4 inflations in Group I, p0.05; 3.2 0.9 inflations vs. 3.0 1.4 inflations in Group II, p0.05).This study showed that MMI probably occurs less frequently after direct stenting.

Mitral inflow velocities are widely used for the evaluation of left ventricular (LV) diastolic function. However, they are closely affected by other factors such as preload. The purpose of this study was to evaluate the usefulness of tissue Doppler velocities obtained from the mitral annulus for the evaluation of ventricular relaxation in patients under different loading conditions. We also evaluated the effect of preload at different sides on the mitral annulus. The study population consisted of 62 consecutive patients (38 male, 24 female with a mean age of 42 +/- 13 years) who have undergone hemodialysis. Both mitral inflow velocities (E wave, A wave, E wave deceleration time and isovolumetric relaxation time) and mitral annulus tissue Doppler velocities (E', A') from the septal, lateral, anterior, posterolateral and inferior sides of the mitral annulus were measured immediately before and after hemodialysis. Mitral inflow E and A wave velocities and E/A ratio decreased significantly (p0.001, p = 0.007, p0.001, respectively) after hemodialysis. Mitral annulus E' wave velocities and E'/A' ratios obtained from five different sides of the annulus also changed significantly (p0.001 for all); however, there was no change in the A' wave velocity (p0.05 for all) after hemodialysis. The decrease in E wave and E/A ratio in mitral inflow measurements and E' velocities and E'/A' ratios in tissue Doppler measurements were correlated with the amount of fluid extracted (for mitral inflow E wave, r = 0.392, p = 0.002 and E/A ratio, r = 0.280 and p = 0.027; for lateral side E', r = 0.329, p = 0.009 and E'/A' ratio, r = 0.286, p = 0.04; for septal side E', r = 0.376, p = 0.003 and E'/A' ratio, r = 0.297, p = 0.019; for anterior side E', r = 0.342, p = 0.007 and E'/A' ratio, r = 0.268, p = 0.035; for posterolateral side E', r = 0.423, p = 0.001 and E'/A' ratio, r = 0.343, p = 0.007; and for inferior side E', r = 0.326, p = 0.01 and E'/A' ratio, r = 0.278, p = 0.029). We conclude that mitral annular velocities obtained by tissue Doppler are preload dependent parameters for the evaluation of LV diastolic function.

To evaluate the feasibility and safety of direct stenting and to compare it with conventional implantation techniques in patients with acute coronary syndrome (ACS).A total of 145 patients were divided into two arms based on the stenting technique used: group I (n = 71) = direct stenting without predilatation group that included only single-vessel procedures and group II (n = 74) = stenting with predilatation group that included only single-vessel conventional stent implantations. The primary endpoint of the study was the major adverse clinical event (MACE) rate in-hospital, at 1 month, and at 6 months and the secondary endpoint was the balloon inflation time (BIT), the number of balloon inflations (NBI), the radiation exposure time (RET), the amount of contrast dye used (ACD) and the no-reflow phenomenon.Primary success rate was 89% in group I and 95% in group II; overall procedural success rate was 94% in group I and 100% in group II. The rate of MACE was not different during the follow-up period between the two groups. The RET, BIT and NBI were significantly lower in group I than in group II (p0.001 for all). The ACD used was also significantly lower in group I than in group II (125 60 ml versus 155 71 ml; p = 0.006). Furthermore, the rate of no-reflow was significantly lower in group I than in group II (2.8% versus 13.5%; p = 0.03).Direct stenting is a feasible and safe technique. It is equivalent to single-vessel conventional stent implantation techniques with respect to MACE rate in-hospital, at 1 month, and at 6 month follow-up in selected patients with ACS.

Carotid sinus massage (CSM) is commonly performed as a bedside test for determining the type and sometimes also the mechanism of different rhythm disturbances, or for routine investigation of older patients who experience syncope, dizziness, or unexplained falls.1 Recently, it has been reported that the response to CSM is affected by the patient's position, and in patients with unexplained syncope or drop attacks, upright CSM is recommended if initial supine CSM is not diagnostic.2 3 On the other hand, time of day at which massage is performed is usually not taken into consideration. Circadian rhythm, which is the variability of physiology and biochemistry of humans in a predictable fashion during a 24 hour period, may also have an effect on response to CSM as well as the patient's position. There has been no study, to our knowledge, that has prospectively evaluated the relation between circadian rhythm and response to CSM. For this reason, we conducted such a study. A total of 120 consecutive patients (mean (SD) age 56.9 (12.4) years, 76 men and 44 women) who were in sinus rhythm were included in the study. Patients with a history or clinical findings consistent with cerebrovascular disease and who had murmurs on carotid arteries were excluded. …

Mitral annulus calcification (MAC) is an independent predictor of coronary artery disease (CAD). The present study was designed to determine whether an association exists between MAC and CAD in patients with dilated cardiomyopathy. Among the 286 patients with MAC on echocardiographic examination who underwent coronary angiography, 55 patients with echocardiographic findings of dilated cardiomyopathy (group I) were compared to 60 age- matched controls without MAC and an echocardiographic diagnosis of dilated cardiomyopathy (group II) who underwent coronary angiography during the same time. There were no differ ences in echocardiographic findings between two groups. The prevalence of CAD was higher in group I when compared to group II (74% vs 28%, p

Amaç: 12 derivasyonlu EKG nin farklı derivasyonları arasında QT interval süresinde değişkenlik birçok klinik durumda ventriküler aritmiler için bir risk göstergesi olarak öngörülürken, QTd-V nin değeri henüz açık değildir. Çalışmanın amacı reentran ventriküler takiaritmilere (VT) duyarlılığı olan hastaları belirlemede ventriküler premature atımlarda QT dispersiyonu’nun (QTd-V) değerini araştırmaktır. Gereç ve Yöntem: Elektrofizyolojik çalışma yapılmış 34 hastada indüklenebilir VT nin tahmini için prekordiyal QTd-V, sinyal ortalamalı EKG de geç potansiyeller ve azalmış sol ventrikül ejeksiyon fraksiyonu karşılaştırıldı. Bulgular: İndüklenebilir VT li 12 hastadaki QTd-V (110±50 msec) VT nin indüklenemediği 22 hastadaki QTd-V den (65±38 msec, p=0.006) daha büyük bulundu. Ejeksiyon fraksiyonu ve geç potansiyel varlığının dahil edildiği çok değişkenli analiz QTd-V nin ventriküler takiaritmilere duyarlı hastaları belirlemede bağımsız bir faktör olmadığını gösterdi. Sonuç: Artmış QTd-V tek başına reentran ventriküler takiaritmilere duyarlılıkla ilintili olsa da, geç potansiyeller ve sol ventrikül ejeksiyon fraksiyonu hesaba katıldığında ilave tanısal bilgi sağlamadığı gözükmektedir.

Coronary artery ectasia (CAE) is characterised by irregular, diffuse, saccular, or fusiform dilatation of the coronary arteries. Although the underlying mechanisms are not fully understood, CAE is considered an original form of vascular remodelling in response to atherosclerosis. However, it is not clear why some patients develop CAE while most do not. Experimental data suggest that activation of the renin angiotensin system may lead to an increased inflammatory response in the vessel wall or to an activation of matrix metalloproteinases.1,2 In addition, an insertion/deletion (ID) polymorphism of angiotensin converting enzyme (ACE) has been associated with coronary vascular tone3 and the development of aneurysms.4 Accordingly, we hypothesised that the gene polymorphism of ACE may be a potential factor influencing the genesis of CAE. We prospectively evaluated 3427 consecutive patients undergoing coronary angiography for the evidence of CAE. Coronary diameters and percent stenosis were measured by using computerised quantitative angiography in a biplane mode (Philips DCI, Eindhoven, Netherlands). CAE was defined as an arterial segment with a diameter of at least 1.5 times the diameter of the adjacent normal coronary artery. If no adjacent normal segment could be identified, the mean diameters of coronary segments in a control group without coronary disease (n = 81) served as normal values. ACE ID genotype was determined in two groups of patients. Group 1 consisted of 152 patients who were …