The role of baseline and post‐procedural frontal plane QRS‐T angles for cardiac risk assessment in patients with acute STEMI

Background

To our knowledge, no study so far investigated the importance of post‐procedural frontal QRS‐T angle f(QRS‐T) in ST segment elevation myocardial infarction (STEMI). The aim of our study was to investigate the role of baseline and post‐procedural f(QRS‐T) angles for determining high risk STEMI patients, and the success of reperfusion.

Methods

A total of 248 patients with first acute STEMI that underwent primary percutaneous coronary intervention (pPCI) or thrombolytic therapy (TT) between 2013 and 2014 were included in this study. Baseline f(QRS‐T) angle was defined as the angle which measured from the first ECG at the time of hospital admission. Post‐procedural (QRS‐T) angle was defined according to the treatment strategy as follows: the angle which measured from the post‐PCI ECG in patients treated with pPCI; the angle which measured from the ECG taken 90 min after onset of therapy in patients treated with TT.

Results

The baseline (101.9° ± 48.0 vs. 72.1° ± 49.1, p = 0.014) and post‐procedural f(QRS‐T) angles (95.7° ± 48.1 vs. 58.1° ± 47.1, p = 0.002) were significantly higher in patients who developed in‐hospital mortality than the patients who did not develop in‐hospital mortality. Also, f(QRS‐T) angle measured at 90 min was significantly lower in patients with successful thrombolysis group compared to failed thrombolysis group (53.2° ± 42.8 vs. 77.3° ± 52.9, p = 0.033), whereas baseline f(QRS‐T) angle was similar between two groups (78.6° ± 53.4 vs. 78.9° ± 54.0, p = 0.976). Multivariate analysis showed that post‐procedural f(QRS‐T) angle ≥89.6° (odds ratio: 3.541, 95% confidence interval: 1.235–10.154, p = 0.019), but not baseline f(QRS‐T) angle, was independent predictor of in‐hospital mortality.

Conclusion

f(QRS‐T) angle may be used as a beneficial tool for determining high risk patients in acute STEMI. Unlike previous studies, we showed for the first time that that post‐procedural f(QRS‐T) can predict in‐hospital mortality and TT failure.

     

Pleural fluid and serum procalcitonin as diagnostic tools in tuberculous pleurisy

BACKGROUND: Diagnosis of tuberculous pleuritis is difficult because of its nonspecific clinical presentation and decreased efficiency of traditional diagnostic methods. We investigated the use of procalcitonin (PCT) concentration in tuberculous pleuritis diagnosis. METHODS: A prospective clinical study was performed with two different patient groups. A total of 28 patients were included: 18 with tuberculosis and 10 with nontuberculous pleurisy. Serum and pleural fluid PCT concentrations were evaluated before treatment. RESULTS: Serum and pleural fluid PCT concentrations were statistically different between tuberculous and nontuberculous pleurisy groups (P = 0.012 and P = 0.004, respectively), even though they were not elevated in relation to the cut-off level of 0.5 ng/mL. A positive and significant correlation was detected between serum and pleural fluid PCT levels (r = 0.49, P = 0.008). Diagnostic specificity and sensitivity values for serum and pleural fluid PCT in discriminating tuberculous from nontuberculous pleurisy were 80% and 72.2%, and 90% and 66.7% at the 0.081 and 0.113 ng/mL cut-off values, respectively. CONCLUSION: Relative to the current cut-off level of 0.5 ng/mL, PCT concentration is not a useful parameter for the diagnosis of tuberculous pleurisy. Because there were PCT levels in patients with tuberculous pleurisy that were below the current cut-off level but were significantly different from those of the nontuberculous group, the use of PCT should be further investigated.     

The Forgotten Variable of Shear Stress in Mitral Annular Calcification: Whole Blood Viscosity

Objective

The aim of this research was to assess the relationship between mitral annular calcification (MAC) and whole blood viscosity (WBV).

Subjects and Methods

A total of 184 patients with MAC and 133 patients without MAC were enrolled in the study. The WBV was calculated with a confirmed formulation using the hematocrit and total plasma protein at a low shear rate (LSR) and high shear rate (HSR). Early diastolic mitral annular velocity (Ea) and late diastolic mitral annular velocity (Aa) were measured using pulse Doppler tissue echocardiography. Pearson''s correlation analysis was performed to assess the relationship between WBV and mitral annular motion velocities. The effects of different variables on the occurrence of MAC were assessed in univariate and multivariate logistic regression analysis.

Results

In patients with MAC, WBV values were significantly higher at HSR (18.04 ± 0.84 vs. 17.25 ± 0.96 208 s^-1, p < 0.001) and at LSR (78.0 ± 14.2 vs. 61.9 ± 17.1 0.5 s^-1, p < 0.001). The WBV at HSR and LSR were significantly correlated with Ea (r = −0.477, p < 0.001; r = −0.385, p < 0.001, respectively) and Aa (r = −0.544, p < 0.001; r = −0.323, p < 0.001, respectively). Multivariate analysis showed that WBV of both shear rates was an independent predictor of MAC. Using the ROC curve, a cut-off value of 70.1 for WBV at LSR had a sensitivity of 83.7% and a specificity of 73.7% (AUC 0.785, p < 0.001) and a WBV cut-off value of 17.5 at HSR had a sensitivity of 79.6% and a specificity of 71.4% (AUC 0.761, p < 0.001) for the prediction of MAC.

Conclusion

Patients with MAC had significantly higher WBV, which independently predicted the presence of MAC. WBV had an inverse correlation with mitral annular motion velocities, indicating that a higher WBV may lead to greater limitation in annular motion and, thus, more calcification.Key Words: Mitral valve calcification, Shear stress, Blood viscosity     

Comparison of traditional risk factors, natural history and angiographic findings between coronary heart disease patients with age <40 and >or=40 years old.

OBJECTIVE: In this study we aimed to examine the angiographic findings, traditional risk factors and natural history of Turkish patients <40 and >or=40 years old with coronary heart disease (CHD). METHODS: The records of 491 patients with stable angina pectoris or acute coronary syndrome (ACS), who had undergone coronary angiography (CAG) were reviewed. The patients <40 years (group 1) and >or=40 years (group 2) were compared. RESULTS: The study population was classified as group 1 with 240 patients (mean age 35.7+/-3.4 years) and group 2 with 251 patients (mean age 61.0+/-9.7 years). Smoking, family history, hypercholesterolemia, hypertriglyceridemia and low levels of high-density lipoprotein cholesterol were more prevalent in group 1 while diabetes mellitus, hypertension was higher in group 2. The common presentation among <40 years patients was ACS whereas stable angina was the most common presentation in patients >or=40 years old. Patients in group 1 showed a preponderance of single-vessel disease whereas patients of group 2 showed dominance of multivessel disease. Early clinical course of patients with ACS in group 1 was better than in group 2. CONCLUSION: Our study shows a significantly different clinical, angiographic and biochemical profile in <40 years patients with CHD compared with >or=40 years patients. Dominance of smoking and dyslipidemias that are the preventable risk factors in premature CHD patients is an important threat for our community health. Healthy life styles should be encouraged beginning from young ages and new precautions about smoking must be taken.     

Usefulness of preprocedural soluble CD40 ligand for predicting restenosis after percutaneous coronary intervention in patients with stable coronary artery disease

CD40-CD40 ligand interaction is involved in the inflammatory pathogenesis of atherosclerosis but clinical data about its role in stent restenosis are still limited. We investigated the effect of preprocedural CD40 ligand (sCD40L) on stent restenosis. We enrolled 36 patients (mean age 61.4 +/- 8.5 years) with stable angina who underwent successful stent implantation. Control angiograms were performed in all patients after 6 months. Plasma sCD40L and high-sensitive C-reactive protein levels were measured before stent implantation and at 1 and 6 months after the procedure. Angiographically proven restenosis rate was 27.8%. Plasma sCD40L levels were significantly higher (preprocedural 0.74 +/- 0.79) and more prolonged in patients with stent restenosis compared with patients without stent restenosis (0.02 +/- 0.22 ng/ml, p < 0.001). According to receiver-operator characteristic analysis, sCD40L > 0.41 ng/ml was the best distinguished parameter between patients with and without restenosis. At the multivariate logistic regression analysis, preprocedural sCD40L was an independent predictor (RR 39.4, 95% confidence interval 4.05 to 383.8, p = 0.002) of stent restenosis after adjusting for confounding variables, including diabetes, reference vessel diameter, lesion length, stent diameter, stent length, and baseline high-sensitive C-reactive protein. Sensitivity, specificity, and positive and negative predictive values and likelihood ratio of preprocedural sCD40L levels in stent restenosis were 78%, 92%, 78%, 92%, and 9.37%, respectively. In conclusion, enhanced inflammation of plaque (increased sCD40L) before percutaneous coronary intervention may increase the rate of stent restenosis. Increased preprocedural sCD40L level is an independent predictor of stent restenosis. We can use this marker for the assessment of risk stratification before planning stent implantation.     

Leucocyte-depleted blood cardioplegia

The effect of the depletion of leucocytes from cardioplegic and initial myocardial reperfusion blood on the inflammatory response and myocardial protection in patients with unstable angina undergoing cardiopulmonary bypass (CPB) was studied. Patients were allocated randomly to a leucocyte-depleted (LD) group or a control group. The LD group received continuous retrograde LD isothermic blood cardioplegia and the control group received isothermic blood cardioplegia. Blood samples were collected at seven time-points before, during and after the procedure. Total leucocyte counts of cardioplegia blood in the LD group were significantly lower than in the control group, but systemic leucocyte and neutrophil counts after CPB did not differ between the groups. The levels of adhesion molecules, cytokines, elastase and malondialdehyde were significantly increased after CPB in both groups and reached peak values 2-6 h after surgery; no other significant differences were found. LD cardioplegia and myocardial reperfusion did not attenuate the endothelial and neutrophil-mediated components of the CPB-induced inflammatory response, which may lead to myocardial reperfusion injury.     

Nitrosative tissue damage and apoptotic cell death in kidneys and livers of naturally ethylene glycol (antifreeze)-poisoned geese.

Three naturally ethylene glycol (EG)-intoxicated geese were investigated for pathological changes, nitrosative tissue damage and apoptotic cell death. Severe degeneration of kidney tubular epithelium and congestion of kidney and liver tissues were observed. Immunohistochemical staining for inducible nitric oxide synthase and nitrotyrosine revealed strong immunoreactivity with both antibodies in kidney and liver tissues compared with the weak immunostaining in the control animals. In both tissues of the EG-intoxicated geese, erythrocytes were also highly immunoreactive with nitrotyrosine antibody. A high degree of apoptotic cell death was present in the kidney tubule epithelium of EG-intoxicated geese. Some apoptotic cells were also observed in the liver. These results show that nitrosative tissue damage and apoptotic cell death takes place in kidney and liver during EG intoxication in geese.     

Analysis of NKX3.1 expression in prostate cancer tissues and correlation with clinicopathologic features

This study aimed to analyze NKX3.1 expression in tissue samples of benign prostate hyperplasia (BPH) and in three different prostate cancer categories. The correlation of NKX3.1 expression with clinical and pathologic features of patients having undergone radical prostatectomy also was investigated. NKX3.1 expression was determined in tissue samples obtained from four different histopathological categories: (1) from patients treated with transurethral prostatectomy for BPH (n = 26), (2) localized prostate cancer patients subjected to radical prostatectomy (n = 38), (3) biopsy samples from prostate cancer patients who were metastatic at the initial admission (n = 10), and (4) tissue samples of prostate cancer patients administered antiandrogens, but who had undergone transurethral prostatectomy for infravesical obstruction (n = 11). Standard immunohistochemical staining was performed using an antiserum raised against recombinant human NKX3.1. Staining was seen in all categories of prostatic tissues. Immunohistochemistry staining scores were lower in prostate cancer patients. The staining scores were significantly higher in patients with BPH compared to metastatic or localized prostate cancer patients. Staining scores of patients with BPH and of those under antiandrogen therapy were similar. No significant correlation was found between NKX3.1 expression and tumor volume, Gleason sum scores, the presence of extraprostatic extension, tumor stage, or serum PSA. NKX3.1 expression is significantly decreased in prostate cancer patients when compared to BPH. However, the decline of NKX3.1 expression was not correlated with prostate cancer progression and was not associated with advanced stage. Thus, NKX3.1 expression is not a clinically valuable prognostic factor.