Serum total bilirubin level is associated with contrast induced nephropathy after primary percutaneous coronary intervention

Contrast Induced Nephropathy (CIN) is a major complication of angiographic procedures. Primary percutaneous coronary intervention (pPCI) is the preferred treatment for ST-segment elevation myocardial infarction (STEMI) but is associated with a risk of CIN. Oxidative stress and free radical damage play a role in the pathogenesis of CIN. Bilirubin has anti-inflammatory and antioxidant activity and has been shown to have a protective effect on endothelial cells. The present study aimed to assess the association between serum bilirubin level and development of CIN after pPCI. Sequential STEMI patients (n = 595) who underwent pPCI between January 2021 and December 2022 were enrolled. Among the participants, 116 (19.5%) developed CIN. Serum total bilirubin level was significantly lower in the CIN group (P = .001). In multivariate logistic regression analysis, serum bilirubin level was found as an independent predictor of CIN. Age, gender, contrast volume, and white blood cell count were other independent predictors of CIN. A higher serum bilirubin level is associated with a lower risk of CIN in the present study. In STEMI patients undergoing pPCI, serum bilirubin level may be helpful to predict the risk of CIN and may help ensure early initiation of preventive treatment and careful follow-up.

Lower LDL-cholesterol levels associated with increased inflammatory burden in patients with acute ST-segment elevation myocardial infarction

OBJECTIVE

Association of low-density lipoprotein cholesterol and highly sensitive C-reactive protein in ST-elevation myocardial infarction patients was assessed in this study.

METHODS

591 consecutive patients who were hospitalized with a diagnosis of ST-elevation myocardial infarction were enrolled and assigned into tertiles according to their serum low-density lipoprotein cholesterol levels. Differences in highly sensitive C-reactive protein among low-density lipoprotein cholesterol tertiles and correlations between highly sensitive C-reactive protein and low-density lipoprotein cholesterol were assessed.

RESULTS

Highly sensitive C-reactive protein levels differed significantly among the groups (p<0.001) and found to be highest in the low-density lipoprotein cholesterol tertile 1 and lowest in the low-density lipoprotein cholesterol tertile 3 (post-hoc p-values: tertile 1 vs. 2 <0.001; tertile 1 vs. 3 <0.001; tertile 2 vs. 3=0.019). There was a negative correlation between hs-CRP and both low-density lipoprotein cholesterol (r=-0.332, p<0.001) and total cholesterol (r=-0.326, p<0.001). There was also a negative correlation between highly sensitive C-reactive protein and high-density lipoprotein cholesterol, though the strength of this relationship was weak (r=-0.103, p=0.014).

CONCLUSION

Lower low-density lipoprotein cholesterol levels are associated with higher inflammatory burden in patients with acute STEMI. Further studies are required to elucidate the significance of low-density lipoprotein cholesterol levels in ST-elevation myocardial infarction settings.

Monocyte to high-density lipoprotein cholesterol ratio is predictive of in-hospital and five-year mortality in ST-segment elevation myocardial infarction

BACKGROUND

We assessed the value of monocyte to high-density lipoprotein cholesterol ratio (MHR) in predicting in-hospital and 5-year mortality and major adverse cardiovascular events (MACE) in ST-segment elevation myocardial infarction (STEMI) patients.

METHODS

A group of 1,598 patients were enrolled and divided into tertiles according to MHR values. The effects of different variables on clinical outcomes were assessed by Cox regression analysis.

RESULTS

MHR was found as an independent predictor of in-hospital mortality (HR = 3.745, 95% CI 1.308-5.950), in-hospital MACE (HR 1.501, 95% CI 1.015-1.993, p = 0.022) and 5-year mortality (HR = 2.048, 95% CI 1.225-4.091, p = 0.014) and 5-year MACE (HR 1.285, 95% CI 1.064-1.552, p = 0.009).

CONCLUSIONS

MHR is an independent predictor of in-hospital and long term mortality and MACE in STEMI.

Red cell distribution width predicts totally occluded infarct-related artery in NSTEMI

Objective Since non-ST segment elevation myocardial infarction (NSTEMI) patients with totally occluded infarct-related artery (TO-IRA) have worse prognosis, it is important to recognize TO-IRA in NSTEMI. Red cell distribution width (RDW) and mean platelet volume (MPV) are novel markers of inflammation and oxidative stress and were associated with poor clinical outcomes in acute coronary syndrome. In the present study, association of RDW and MPV with the presence of TO-IRA in NSTEMI was investigated. Methods Data of 201 consecutive patients who underwent coronary angiography with a diagnosis of NSTEMI were analyzed. Independent predictors of TO-IRA were investigated with logistic regression analysis. Results Sixty-six (32.8%) of the patients had TO-IRA. In patients with TO-IRA, RDW and troponin-T were significantly higher and left ventricular ejection fraction (LVEF) was lower. MPV did not differ between groups. Circumflex (CX) IRA was more common in TO-IRA group. The ROC curve analysis showed that the RDW at a cut-point of 13.95% has 76% sensitivity and 66% specificity in detecting TO-IRA. RDW, troponin-T, LVEF and CX-IRA were independent predictors of TO-IRA in NSTEMI, but MPV was not. Conclusion RDW is a cheap and readily available marker that may have a role to predict TO-IRA in NSTEMI.

White blood cell count to mean platelet volume ratio: A novel and promising prognostic marker for ST-segment elevation myocardial infarction

BACKGROUND

Increased white blood cell (WBC) count is associated with increased mortality in patients with ST-segment elevation myocardial infarction (STEMI). We aimed to evaluate predictive value of admission WBC to mean platelet volume (MPV) ratio (WMR) on prognosis in patients undergoing primary percutaneous coronary intervention (pPCI) for STEMI.

METHODS

A total of 2,603 consecutive patients with STEMI who underwent pPCI were recruited for the study. Follow-up data were obtained from digital records, patient files or by telephone interview with patients, family members, or primary care physicians.

RESULTS

WMR has the highest area under receiver operating characteristic (ROC) curve and pairwise comparisons of the ROC curves revealed that WMR has the higher discriminative ability for long-term mortality than WBC, MPV, red blood cell distribution with (RDW), WBC-MPV combination, and platelet to lymphocyte ratio and neutrophil to lymphocyte ratio (PLR-NLR) combination in patients undergoing pPCI for STEMI (a WMR value of 1,653.47 was also found as threshold value for mortality with 75.4% sensitivity and 87.3% specificity by ROC curve analysis).

CONCLUSIONS

Higher WMR value on admission was associated with worse outcomes in patients with STEMI and independently better predicted the long-term mortality than other complete blood count components, such as MPV, RDW, PLR-NLR and WBC-MPV combinations.

Usefulness of the Macruz Index for Predicting Successful Percutaneous Mitral Balloon Valvuloplasty in Patients with Mitral Stenosis

OBJECTIVE

The aim of this study was to determine whether the Macruz index (P/P-R segment) could predict the severity of valvular involvement and the success of percutaneous mitral balloon valvuloplasty (PMBV) in patients with mitral stenosis (MS).

SUBJECTS AND METHODS

Sixty-one patients with MS eligible for PMBV and 72 healthy subjects (61 females and 11 males) with sinus rhythm were enrolled into this study. PMBV was performed in all patients using a percutaneous transseptal antegrade approach and a multitrack balloon technique. The P/P-R segment ratio and echocardiographic variables were measured before and 48-72 h after the procedure. The optimal cutoff point for differences in the Macruz index to determine clinical success was evaluated by receiver operating characteristic analysis by calculating the area under the curve as giving the maximum sum of sensitivity and specificity for the significant test.

RESULTS

In the patient group (mean age 42.9 ± 11.1 years), the preprocedural Macruz index was significantly higher than in the control group (2.79 ± 1.03 vs. 1.29 ± 0.11; p < 0.001). In the successful-procedure group (n = 53), the mean postindex value was significantly lower (2.12 ± 0.71 vs. 2.81 ± 1.0, p = 0.020), and the decrease in the Macruz index was significantly higher than in the unsuccessful-procedure group (p = 0.007). An index decrease of 0.105 was the best cutoff value to distinguish the successful-PMBV group from the unsuccessful- PMBV group (area under the curve = 0.888, 95% confidence interval 0.788-0.988, p < 0.001).

CONCLUSION

The Macruz index was significantly higher in patients with MS compared to healthy subjects. A greater decrease in the Macruz index was associated with a successful PMBV.

Red Cell Distribution Width Can Predict the Significance of Angiographically Intermediate Coronary Lesions

OBJECTIVE

In the present study, the association between red cell distribution width (RDW) with functional significance of intermediate coronary artery lesions was investigated.

MATERIALS AND METHODS

Two hundred and forty-six consecutive patients, 168 males and 78 females, who underwent fractional flow reserve (FFR) measurement for angiographically intermediate coronary stenosis (40-70% in quantitative coronary analysis) in the left anterior descending coronary artery were enrolled into the study. The functional significance of intermediate coronary artery lesions was determined by FFR measurement. An FFR value <0.75 was defined as functionally significant. Venous blood samples were taken within 48 h before the FFR measurement, and RDW levels were determined by a Coulter LH Series hematology analyzer. Logistic regression analysis was used to examine the association between functional significance in FFR measurement and other variables.

RESULTS

Of the 246 patients, 62 (25.2%) exhibited significant functional stenosis (FFR <0.75) in the FFR measurement. The mean RDW level was significantly higher in patients with significant stenosis (14.19 ± 0.73 vs. 13.69 ± 0.77, p < 0.001). In stepwise multivariate logistic regression analysis, RDW (OR = 2.489, 95% CI = 1.631-3.799, p < 0.001) and male gender (OR = 2.826, 95% CI = 1.347-5.928, p = 0.006) were independent predictors of significant functional stenosis.

CONCLUSION

Increased RDW levels were associated with functional significance of angiographically intermediate coronary artery stenoses.

Impaired cardiac autonomic functions in apparently healthy subjects with vitamin D deficiency

OBJECTIVES

Vitamin D (VitD) deficiency affects the cardiovascular system via endocrine, paracrine, and autocrine pathways. Limited data are available regarding cardiac autonomic dysfunction in VitD deficiency. The aim of this study was to assess the cardiac autonomic functions by using heart rate recovery index (HRRI) and heart rate variability (HRV) in apparently healthy subjects with VitD deficiency.

METHODS

A total of 24 VitD deficient and 50 age-, gender-, and body mass index-matched VitD sufficient healthy participants who admitted to outpatient clinics at a tertiary centre were enrolled. All study participants underwent Treadmill exercise test and 24-hour Holter recording to assess cardiac autonomic functions. HRRIs were calculated by subtracting first, second, and third minute heart rates during recovery period from maximal heart rate.

RESULTS

Mean HRR1 (28.0 ± 8.3 vs 42.8 ± 6.4, P < 0.001), HRR2 (41.1 ± 11.2 vs 60.8 ± 10.4, P < 0.001), and HRR3 (44.9 ± 13.3 vs 65.9 ± 9.8, P < 0.001) were significantly higher in VitD sufficient group compared to VitD deficient group. HRV parameters as, SDNN (P = 0.040), SDANN (P < 0.001), RMSSD (P < 0.001), PNN50 (P < 0.001), and HF (P < 0.001) were significantly decreased in patients with VitD deficiency; but LF (P < 0.001) and LF/HF (P = 0.003) were significantly higher in VitD deficient group. Serum 25(OH)D level was positively correlated with HRRIs (P < 0.001), PNN50, RMSSD, SDANN, and HFnu; negatively correlated with LFnu and LF/HF (P < 0.05). Also, multivariate linear regression analysis showed that serum 25(OH)D level was significantly associated with HRRIs and HRV parameters (P < 0.001).

CONCLUSION

Our study results suggest that cardiac autonomic functions are impaired in patients with VitD deficiency despite the absence of overt cardiac involvement and symptoms. Further studies are needed to elucidate the prognostic significance and clinical implications of impaired autonomic functions in patients with VitD deficiency.

Fragmented QRS can predict severity of aortic stenosis

BACKGROUND

Fragmented QRS (fQRS) is an indicator of nonhomogeneous ventricular activity caused by myocardial fibrosis. Aortic stenosis (AS) is known to be a cause of myocardial fibrosis. We aimed to investigate the relationship of fQRS with severity of AS, echocardiographic, and electrocardiographic findings, and development of atrial fibrillation and manifest heart failure in AS patients.

METHODS

One hundred four patients with moderate and severe AS were recruited for the study. Patients with mitral or tricuspid stenosis, previous myocardial infarction, segmental wall motion abnormality or left ventricular ejection fraction (LVEF) below 50% and patients with complete-incomplete BBB and pacemaker rhythm were excluded.

RESULTS

Mean age of the patients was 69 ± 14.8 and 73.1% had fQRS. Patients with fQRS had lower LVEF, higher mean QRS duration, intrinsic deflection, Cornell voltage, Romhilt-Estes Score, systolic pulmonary artery pressure, mean and peak systolic transaortic gradients and left atrium diameter. Manifest heart failure was more frequent in patients with fQRS. In stepwise multivariate logistic regression analyze, manifest heart failure, peak systolic transaortic gradient, LVEF, intrinsic deflection, strain pattern and Cornell voltage were independently associated with fQRS. Strain pattern and fQRS were found as independent predictors of severe AS.

CONCLUSIONS

fQRS is independently associated with the severity of AS while traditional LVH criteria, except strain pattern, are not. fQRS may be better than traditional ECG criteria of LVH and echocardiographic LVH as an indicator of myocardial fibrosis in AS. Thus, fQRS may have a role in determining the severity and prognosis of AS.

The ratio of contrast volume to glomerular filtration rate predicts in-hospital and six-month mortality in patients undergoing primary angioplasty for ST-elevation myocardial infarction

BACKGROUND

The aim of this study is to determine the impact of ratio of contrast volume to glomerular filtration rate (V/GFR) on development of contrast-induced nephropathy (CIN) and long-term mortality in patients with ST-segment elevation acute myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

METHODS

A total of 645 patients with STEMI undergoing primary PCI was prospectively enrolled. CIN was defined as an absolute increase in serum creatinine > 0.5 mg/dL or a relative increase > 25% within 48 h after PCI. The study population was divided into tertiles based on V/GFR. A high V/GFR was defined as a value in the third tertile (> 3.7).

RESULTS

Patients in tertile 3 were older, had higher rate of smoking, diabetes mellitus and CIN, lower left ventricular ejection fraction, hemoglobin, and systolic and diastolic blood pressure compared to tertiles 1 and 2 (p < 0.05). V/GFR was found an independent predictor of in-hospital and 6-month mortality. We found 2 separate values of V/GFR for 2 different end points. While the ratio of 3.6 predicted in-hospital mortality with 78% sensitivity and 82% specificity, the ratio of 3.3 predicted 6-month mortality with 71% sensitivity and 76% specificity. Survival rate decreases as V/GFR increases both for in-hospital and during 6-month follow-up. Diabetes mellitus and multivessel disease were other predictors of in-hospital mortality.

CONCLUSIONS

High V/GFR level is associated with increased in-hospital and long-term mortality in patients with STEMI undergoing primary PCI.

Gastrointestinal bleeding secondary to interaction of Artemisia absinthium with warfarin

Artemisia absinthium, also known as wormwood, is used widely as an herbal medicine. In this report, we introduce an 82-year-old Turkish woman who was treated with warfarin for atrial fibrillation and was hospitalized for gastrointestinal bleeding as a result of extremely elevated international normalized ratio (INR) after consumption of A. absinthium. Naranjo adverse drug reaction probability scale score was 6, which indicated a probable relationship between the patient's elevated INR and her concomitant use of wormwood and warfarin. Clinicians should be vigilant about potential dangers of herbal medicines taken with conventional drugs, and patients taking drugs with a narrow therapeutic index, such as warfarin, should be educated about avoiding consumption of herbal medicines.