Novel predictor of pulmonary arterial hypertension: Monocyte to HDL cholesterol ratio

Monocyte to HDL cholesterol ratio (MHR), lymphocyte to monocyte ratio (LMR), and neutrophil to lymphocyte ratio (NLR) have been proposed as novel systemic inflammatory markers. The aim of this study was to explore the association between MHR, LMR and NLR with pulmonary arterial hypertension (PAH). The study is a single-center, retrospective Cross-sectional study. The study group consisted of 73 patients with PAH and the control group 77 participants without cardiac pathology as determined by echocardiography. On admission, blood sampling to calculate MHR, LMR, NLR, and detailed clinical data were obtained. According to the Pearson test, systolic pulmonary artery pressure (PAP) value Higher MHR, NLR and lower LMR that indicates an enhanced inflammation were significantly increased in patients with PAH when compared with controls. Compared to many other inflammatory markers, these markers are widely available. positively correlated with the MHR and NLR (r:.35, P < .001 and r:.33, P < .001, respectively), but negatively correlated with LMR (r: -.26, P = .001). After multivariate logistic regression analysis, MHR, LMR, and NLR remained as significant predictors of PAH (OR: 2.651, 95% CI: 1.227-5.755, P = .007; OR: 0.647, 95% CI:0.450-0.931, P = .005; OR: 1.350, 95% CI: 1.054-1.650 P = .030, respectively).

Predictive value of lymphocyte to monocyte ratio for cardiac syndrome X

OBJECTIVE

Cardiac syndrome X (CSX) is typically described with ischemia in stress tests in addition to angina-like chest pain and without stenosis in coronary angiography. We aimed at determining the relationship between LMR and CSX.

PATIENTS AND METHODS

We retrospectively collected patients with CSX between January 2016 and December 2019. Patients with typical angina-like chest pain, normal 12-lead electrocardiography at rest, a positive response to the exercise test (> 0.1 mV ST-segment depression at 80 ms after the J point in two or more contiguous leads) or ischemia on myocardial perfusion scintigraphy and normal coronary angiography were included in the study as CSX patients.

RESULTS

This study consisted of 116 patients with CSX and 153 control groups. The mean age of the patients with CSX was 52.7±9.7 years, and the mean age of the control group was 53.7±10.6 years (p= 0.416). The patients with CSX were more likely to have higher monocyte counts and LMR. According to the Pearson correlation test, the CRP value negatively correlated with the LMR. In multivariate logistic regression analysis, LMR remained a significant predictor of CSX. In ROC analysis, LMR < 4.1 had 64% sensitivity and 50% specificity (ROC area under curve: 0.587, 95% CI: 0.519-0.655, p=0.015) in accurately predicting a CSX diagnosis.

CONCLUSIONS

We showed that lower LMR levels were associated with the presence of CSX.

Monocyte to high-density lipoprotein cholesterol and lymphocyte to monocyte ratios are predictors of in-hospital and long-term mortality in patients with acute coronary syndrome

OBJECTIVE

We aimed to determine the relationship between LMR and MHR and in-hospital and long-term mortality in patients with ACS.

METHODS

We retrospectively collected patients with ACS undergoing coronary angiography between January 2012 and December 2013.

RESULTS

In total, 825 patients with a mean age of 62.4 ± 12.9 years (71.3% male) were enrolled in the study. Patients were divided into three tertiles based on MHR levels and LMR levels. In-hospital mortality of the patients was significantly higher amongst patients in the upper MHR tertile when compared with the lower and middle MHR tertile groups [30 (10.9%) vs 8 (2.9%) and 14 (5.1%); P < .001, P = .009, respectively]. Five-year mortality of the patients was significantly higher amongst patients in the upper MHR tertile when compared with the lower and middle MHR tertile groups [84 (30.5%) vs 48 (17.5%) and 57 (20.7%); P < .001, P = .005, respectively]. In-hospital mortality of the patients was significantly higher amongst patients in the lower LMR tertile when compared with the upper and middle LMR tertile groups [25 (9.1%) vs 10 (3.6%) and 17 (6.2%); P = .007, P = .130, respectively]. Five -year mortality of the patients was significantly higher amongst patients in the lower LMR tertile when compared with the upper and middle LMR tertile groups [77 (28.0%) vs 47 (17.1%) and 65 (23.6%); P = .001, P = .142, respectively].

CONCLUSION

We have shown that high MHR and low LMR were significant and independent predictors of in-hospital and long-term mortality in patients with ACS.

Increased monocyte-to-HDL cholesterol ratio is related to cardiac syndrome X

OBJECTIVE

Cardiac syndrome X (CSX) is typically identified with ischaemia in treadmill exercise test or stress myocardial perfusion scintigraphy as well as angina-like chest pain without stenosis in coronary angiography. The purpose of the present study is to investigate the association between cardiac syndrome X and monocyte-to-HDL cholesterol ratio (MHR) which is a new marker associated with inflammation.

PATIENTS AND METHODS

A total of 230 patients (105 patients with cardiac syndrome X and 125 normal controls) were included in the study. Peripheral venous blood samples were drawn from all study population before coronary angiography for measuring MHR and other haematological parameters.

RESULTS

The patients with cardiac syndrome X were more likely to have higher platelet counts, plateletcrit (PCT), monocyte count and MHR values. Monocyte count and MHR of the CSX group were significantly higher than the control group [0.53 (0.35-1) vs. 0.49 (0.23-0.96); p = .002, .011 (0.006-0.038) vs. 0.010 (0.004-0.034); p < .001, respectively]. HDL-cholesterol levels of the CSX group were significantly lower than the control groups (46.3 ± 10.1 vs. 49.6 ± 11.6; p = .021). Higher MHR and PCT values were found to be associated with the presence of CSX by multivariate logistic regression analysis.

CONCLUSIONS

Elevated MHR level independently was found in association with the presence of CSX. The value of MHR appears additive to conventional expensive methods commonly used in CSX prediction.

Coronary sinus dilatation is a sign of impaired right ventricular function in patients with heart failure

OBJECTIVE

The coronary sinus (CS) has been largely ignored by physicians due to a lack of adequate data about the importance of CS enlargement in patients with heart failure (HF). We aimed to assess whether CS dilatation develops in patients with HF and to demonstrate its relation with global myocardial function of the right ventricle (RV).

METHODS

In this cross-sectional study, 45 healthy subjects and 95 HF patients exhibiting left ventricular systolic dysfunction on echocardiographic examination (EF <45%) secondary to ischemic (n=56) or idiopathic dilated cardiomyopathy (DCM) (n=39) were enrolled. Patients with severe renal dysfunction and/or valve disease were excluded. CS was measured by echocardiography from the posterior atrioventricular groove in the apical four-chamber view. The RV myocardial performance index (MPI), which reflects both systolic and diastolic function of the ventricle, was detected using tissue Doppler imaging, and patients with an RV MPI >0.55 were defined as having impaired RV myocardial function. ANOVA, Kruskal-Wallis, Pearson's correlation, and multivariate logistic regression analyses were used for the statistical analysis.

RESULTS

The CS and RV MPI values were significantly greater both in patients with ischemic and idiopathic DCM than in controls (8.79±1.7 mm and 8.33±2.1 mm vs. 5.74±0.6 mm, and 0.64±0.07 and 0.62±0.08 vs. 0.43±0.02; p<0.001 for both, respectively). For the prediction of HF patients with impaired RV function, the cut-off value for the diameter of the CS was 7.35 mm, with a sensitivity of 83% and a specificity of 79%.

CONCLUSION

The CS diameter can be used as a novel echocardiographic marker that provides information about impaired RV function in patients with HF.

A simple method for the assessment of arterial stiffness in pre-eclamptic patients

BACKGROUND

Arterial stiffness (AS), the term describes the rigidity of arterial walls, and its hemodynamic results have been shown to be associated with increase in future cardiovascular events. Women with pre-eclampsia in their past pregnancies have a higher risk of developing cardiovascular disease later in life. The goal of this study was to assess AS using a non-invasive and simple oscillometric method in pregnant women with and without pre-eclampsia.

METHODS

Ninety pregnant women, forty-five of which had pre-eclampsia, were included in the study. The vascular measurements were performed with a Mobil-O-Graph 24 h PWA Monitor, an automatic oscillometric device. Statistical analysis was performed using the Chi-square, independent sample t-test or the Mann-Whitney U test, Pearson correlation, and linear regression tests.

RESULTS

All the vascular function parameters were significantly higher in the patients with pre-eclampsia. The pulse wave velocity (PWV) values found in the pre-eclampsia group were positively correlated with gestational age, maternal age, glucose level, creatinine level, augmentation index, and central blood pressure. Using linear regression analysis, the PWV values were confirmed to be positively correlated with gestational age, maternal age, and central systolic blood pressure. The women with severe pre-eclampsia had significantly higher blood pressures, PWV values, augmentation indices, and cardiac outputs when compared with the patients with mild pre-eclampsia.

CONCLUSION

Oscillometric PWV measurement is already accepted as the most reproducible quick, simple, and inexpensive non-invasive method for the assessment of large artery stiffness. It can be applied to evaluate the AS and also aid in detecting future cardiovascular risk of patients with pre-eclampsia.

Relationship between platelet-to-lymphocyte ratio and coronary slow flow

OBJECTIVE

The coronary slow flow phenomenon (CSFP), which is characterized by delayed distal vessel opacification in the absence of significant epicardial coronary disease, is an angiographic finding. The aim of this study is to investigate the association between platelet-to-lymphocyte ratio (PLR) and coronary blood flow rate.

METHODS

This is a retrospective observational study. It was based on two medical centers. A total of 197 patients undergoing coronary angiography were included in the study, 95 of whom were patients with coronary slow flow without stenosis in coronary angiography and 102 of whom had normal coronary arteries and normal flow.

RESULTS

The PLR was higher in the coronary slow flow group compared with the control groups (p=0.001). In the correlation analysis, PLR showed a significant correlation with left anterior descending (LAD) artery thrombolysis in myocardial infarction (TIMI) frame count. After multiple logistic regression, high levels of PLR were independently associated with coronary slow flow, together with hemoglobin.

CONCLUSION

PLR was higher in patients with CSFP, and we also showed that PLR was significantly and independently associated with CSFP.

Platelet-to-lymphocyte ratio is a predictor of in-hospital mortality patients with acute coronary syndrome

Objective:

Platelets and inflammatory cells are vital elements of acute coronary syndromes (ACS). Recent studies have shown that the plateletto-lymphocyte ratio (PLR) is associated with several malignancies; however, there are not enough data in cardiovascular diseases. Therefore, the aim of this study was to explore the association between PLR and in-hospital mortality in patients with ACS.

Methods:

We retrospectively collected patients with ACS undergoing coronary angiography. Total and differential leukocyte counts were measured by an automated hematology analyzer.

Results:

This study is single-centered and observational. In total, 587 patients with a mean age of 61.8±13.1 years (68.4% male) were enrolled in the study. Patients were divided into 3 tertiles based on PLR levels. In-hospital mortality was significantly higher among patients in the upper PLR tertile when compared with the middle and lower PLR tertile groups [29 (14.8%) vs. 17 (8.7%) and 2 (1.0%); p<0.001]. In the multiple logistic regression analysis, a high level of PLR was an independent predictor of in-hospital mortality, together with age, total leukocyte count, and creatinine. Using a cutoff point of 142, the PLR predicted in-hospital mortality with a sensitivity of 69% and specificity of 63%.

Conclusion:

Different from other inflammatory markers and assays, PLR is an inexpensive and readily available biomarker that may be useful for cardiac risk stratification in patients with ACS.

Prognostic role of incidental pleural effusion diagnosed during echocardiographic evaluation

BACKGROUND

The purpose of this study was to determine the long-term prognostic implications of incidental pleural effusion (PE) detected during echocardiographic examination and its relationship with concomitant diseases.

HYPOTHESIS

The study hypothesis is to test whether incidental pleural PE detected during echocardiographic examination be used as a prognostic marker.

METHODS

The study was performed by evaluating patient records (N = 251) in whom PE was incidentally detected during echocardiographic examination in a tertiary hospital between 1999 and 2012. The patients were classified into 4 major groups according to the concomitant primary disease: malignancy, and cardiovascular, renal, and pulmonary diseases. The total survival time was obtained from hospital records for patients who died during the hospital stay and social security institution records for patients with out-of-hospital death.

RESULTS

One-year and 5-year life expectancies of PE cases concomitant with different disorders were as follows; heart failure (n = 151), 81% and 70%; malignancies (n = 45), 53% and 44%; pulmonary diseases (n = 37), 89% and 78%; renal diseases (n = 18), 100% and 83%; respectively. PE associated with heart failure, renal disease, and pulmonary disease had similar (P > 0.05 for all) and favorable outcomes compared to PE associated with malignancies (P < 0.001).

CONCLUSIONS

The prognosis of incidental PE was the worst in patients with concomitant malignancies; however, PE associated with nonmalignant diseases including heart failure, pulmonary disease, and renal disease have similar and favorable outcomes.

Effects of lying position on P-wave dispersion in patients with heart failure

OBJECTIVE

It was the aim of this study to investigate the effects of the right lateral decubitus, left lateral decubitus and supine lying position on P-wave dispersion (PWD) in patients with heart failure (HF).

SUBJECTS AND METHODS

Seventeen patients with HF whose ejection fraction was <35% were included in the study. Right lateral decubitus, left lateral decubitus and supine electrocardiogram (ECG) recordings were obtained. The recordings for each of the three positions were taken after the patients had maintained each position for 30 min to ensure a stabilized hemodynamic position. For the baseline recording, in supine position, there was no 30-min waiting period before the ECG.

RESULTS

After the right lateral decubitus position, there was a statistically significant reduction in the longest P-wave duration (100.0 ± 14.5 and 84.7 ± 16.2 ms; p = 0.001) and a significant decrease in PWD (41.7 ± 8.0 and 24.1 ± 7.1 ms; p < 0.0001). After the left lateral decubitus position, there was no significant change between the baseline PWD values (41.7 ± 8.0 and 40.2 ± 9.7 ms; p = 0.606). After the supine position, there was no significant change between the baseline PWD values (41.7 ± 8.0 and 39.7 ± 9.4 ms; p = 0.427).

CONCLUSION

Our study revealed that patients' PWDs and maximum P-wave durations were lower in the right lateral decubitus lying position than in other positions. The clinical implication of this study needs to be further explored.

[Comparison of controlled pressure belt -allowing mobility to sandbags after percutaneous coronary intervention: pilot study]

OBJECTIVES

We aimed to investigate the efficacy and safety of a belt mechanism (anjiobelt), which we developed recently and patented, which allows mobility after coronary operations and the application of adjustable pressure to the femoral artery.

STUDY DESIGN

Between October 2012 and April 2013, 189 consecutive patients undergoing percutaneous coronary intervention electively or due to acute coronary syndrome were enrolled. There were 96 patients in the sandbag group and 93 patients in anjiobelt group. Manual compression was applied to the femoral artery until reaching primary homeostasis. Then, a 4-5 kilogram sandbag or anjiobelt was placed. Mobilization was allowed in case of need in the anjiobelt group. Twenty-four hours after the procedure, superficial bruising in the femoral region, hematoma, pseudo-aneurysm, and arteriovenous fistula, as femoral artery complications, were noted using Doppler ultrasound.

RESULTS

Hematoma occurred more frequently in the sandbag group. Hematoma of <1 cm developed in 52 patients with sandbag and in 25 patients with anjiobelt (p<0.0001), while hematoma of 1-5 cm developed in 5 patients with sandbag and in 3 patients with anjiobelt (p<0.0001). Femoral artery pseudoaneurysm was seen in 4 patients (2 with anjiobelt, 2 with sandbag; p=0.975).

CONCLUSION

Anjiobelt significantly reduces the incidence of hematoma in comparison to conventional sandbag in patients undergoing percutaneous coronary intervention. Other complications of the femoral region in terms of efficiency and safety appear to be similar to those observed with sandbag. The main problems occurring in these patients due to absolute immobilization have been eliminated with the anjiobelt.

Both-sided native valve endocarditis in an intravenous drug misuser

Infective endocarditis (IE) is more common in left heart chambers in the general population. Right-sided IE is increased especially in intravenous drug misusers. However, involvement of both right and left heart chambers is extremely rare in these patients. In this study, we present the case of a 26-year-old male intravenous drug misuser, hospitalised with Staphylococcal tricuspid valve IE complicated with pulmonary septic embolism. After 10 days, an echocardiogram revealed vegetation on the mitral valve in addition to unchanged tricuspid valve vegetation. IE can be a rapidly progressive disease despite the medical treatment in intravenous drug misusers. Generally, the right-sided IE is common in intravenous drug misusers; however, as in our case, it may involve left heart chambers as well. Therefore, in the right-sided IE cases, a serial echocardiographic examination of both heart chambers is strictly recommended.

Cardiac metastasis of a low-grade myofibroblastic sarcoma

We aim to present a rare case of low-grade myofibroblastic sarcoma arising in the inguinal region accompanied by cardiac metastasis. A 36-year-old male patient suffering from recurrent inguinal swelling was operated on and the initial histopathological evaluation mistakenly diagnosed the condition as benign. During follow-up, a recurrence of mass was detected in the same region and a pathological examination revealed a low-grade myofibroblastic sarcoma. Cardiac metastasis was diagnosed shortly before rapid disease progression and death. The learning points relevant to this case are as follows: (1) Echocardiographic screening in patients with noncardiac myofibroblastic sarcomas may be helpful in the detection of silent metastasis. (2) Low-grade myofibroblastic sarcomas in the inguinal region may be misdiagnosed as benign after enucleation. Thus, rigorous histopathological examination of myofibroblastic sarcomas is crucial. (3) According to our knowledge, this is the first report of a low-grade myofibroblastic sarcoma to have a potential for cardiac metastasis with potentially fatal course.

Non-valvular atrial fibrillation in the elderly; preliminary results from the National AFTER (Atrial Fibrillation in Turkey: Epidemiologic Registry) Study

OBJECTIVE

This study aimed at the assessment of the clinical approach to atrial fibrillation (AF) in the older population and the consistency with the guidelines based on the records of the multicenter, prospective AFTER (Atrial Fibrillation in Turkey: Epidemiologic Registry) study.

PATIENTS AND METHODS

2242 consecutive patients admitted to the Cardiology Outpatient Clinics of 17 different tertiary Health Care Centers with at least one AF attack determined on electrocardiographic examination, were included in the study. Among the patients included in the study, 631 individuals aged 75 years and older were analyzed.

RESULTS

The mean age of the patients was determined as 80.3±4.2 years. The most frequent type of AF in geriatric population was the persistent-permanent type with a percentage of 88%. 60% of the patients with AF were female. Hypertension was the most common co-morbidity in patients with AF (76%). While in 16% of patients a history of stroke, transient ischemic attack or systemic thromboembolism was present, a history of bleeding was present in 14% of the patients. 37% of the patients were on warfarin treatment and 60% of the patients were on aspirin treatment. In 38% of the patients who were on oral anticoagulant treatment, INR level was in the effective range.

CONCLUSIONS

The rate of anticoagulant use in the elderly with AF was 37% and considering the reason of this situation was the medication not being prescribed by the physician, one should pay more attention particularly in the field of treatment.

An Iatrogenically Unmasked Life Threatening Disease: Brugada Syndrome

Brugada syndrome is a life threatening disease that is usually overlooked during emergency service admissions. It is characterized by typical electrocardiography resembling right bundle branch block, static or dynamic ST-segment elevation in leads V 1-3. There is familial tendency in some cases. A majority of patients have a structurally normal heart and are likely to remain asymptomatic, however they may present to emergency departments with syncope and various serious arrhythmias. Therefore it is crucially important for emergency medicine physicians not to omit this potential diagnosis. Herein we report a case with Brugada syndrome which was iatrogenically unmasked after propafenone administration for atrial fibrillation.

Relation of interatrial duration and p wave terminal force as a novel indicator of severe mitral regurgitation

OBJECTIVES

Interatrial duration is defined as prolonged p wave on electrocardiogram. p waves with a negative terminal phase recorded in V1 enclosing an area of one small square on the electrocardiogram is significantly and strongly correlated with interatrial duration. The aim of study was to investigate whether interatrial duration with p terminal force can be used as reflection of echocardiographic severity of mitral regurgitation.

MATERIALS AND METHODS

Sixty two consecutive patients with mitral regurgitation. were prospectively studied. Age/gender matched 57 subjects who had normal mitral structure and did not have mitral regurgitation. Patients with mitral regurgitation referred to a single cardiac center for echocardiography and who met the entry criteria documented moderate or severe mitral regurgitation with sinus were included. The interatrial duration was defined on the routine 12-lead electrocardiogram (50 mm/s, 10 mm/mV) using the greatest duration of p waves from D2, D3, AVF and V1.

RESULTS

There was a positive correlation between interatrial duration (>/= 110 ms) and effective regurgitant orifice (r = 0.3, p < 0.001). However, left atrial diameter and brain natriuretic peptide were significantly higher in cases with mitral regurgitation. There was also strong correlation between interatrial duration (>/= 110 ms) and p terminal force and left atrial diameter. ROC analysis revealed that interatrial duration of > 110 msec. could predict of severe mitral regurgitation with 88% sensitivity and 100% specificity.

CONCLUSIONS

Severe mitral regurgitation, left atrial diameter was correlated with p terminal force and interatrial duration. Significant interatrial duration (>/= 110 ms) and p terminal force might be considered as novel indicators of severe mitral regurgitation.

Progress of Untreated Massive Cardiac Echinococcosis?Echocardiographic Follow-Up

A 56-year-old man was admitted with chest pain and dyspnea. Echocardiographic evaluation revealed a giant cystic cardiac mass with multiple loculations at interventricular septum extended to inferoposterior region protruding inside the cavity. The patient refused surgical therapy. His complaints persisted without significant changes after 5 months. Second echocardiographic evaluation revealed conjugation of previous multiple cyst to gigantic intramyocardial cyst and minimal pericardial effusion. We intend to illustrate herein an unusual echocardiographic appearance and progress of an untreated massive "cardiac echinococcosis." If cardiac hydatid cyst is left untreated it may transform to large cavity with a high risk of rupture.