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PP-040 THE SUCCESSFUL USE OF ENOXAPARINE IN THE LACK OF BIVALIRUDIN IN A PATIENT WITH CHRONIC LYMHOCYCTIC LEUKEMIA AND THROMBOCYTOPENIA WHO UNDERWENT PERCUTANEOUS CORONARY REVASCULARIZATION
Cardiology Posters / International Journal of Cardiology 140, Supplement 1 (2010) S1–S93
is a rare condition which may cause acute coronary syndromes. Reported incidence was 0.1%. Approximately three-fourths of the cases were women with a predilection to occur in LAD, whereas right coronary artery lesions predominate in men, in contrast to our case. Classically, the patients are divided into three groups: a peripartum, atherosclerotic and idiopathic group. However several theories have been postulated; the exact pathophysiologic mechanism has not been fully clarified yet. It is thought to be the consequence of an intramural hematoma of a coronary artery, resulting in a false lumen which compresses the true lumen, with subsequent myocardial ischemia. The clinical presentation of patients depends on the extent and severity of the dissection, and ranges from unstable angina to sudden cardiac death. The major diagnostic tool is coronary angiography; and if necessary it may be supported by intravascular ultrasound. Treatment should be individualized. Conservative approach, primary percutaneous coronary intervention, coronary artery by-pass surgery is current treatment options.
PP-039 EVALUATION OF PRECORDIAL ST SEGMENT DEVIATIONS IN ACUTE AND CHRONIC TOTAL OCCLUSIONS OF RIGHT CORONARY ARTERY Mehmet Emin Kalkan, Mahmut Acikel, Sakir Arslan, Enbiya Aksakal, Serdar Sevimli, Fuat Gundogdu, Hakan Tas, Eftal Murat Bakirci Department of Cardiology, Faculty of Medicine, Ataturk University, Erzurum, Turkey Objective: The aim of this study was to examine the patients who have acute, subacute and chronic right coronary artery (RCA) total occlusions but normal left coronary arteries. Additionally, the relation between precordial ST segment deviation and the level of total occlusion at RCA were examined. Methods: This study, retrospectively, were performed with 324 patients that were chosen between consecutive 23922 people applied coronary angiography. Total occlusion is determined as ceasing course of coronary artery abruptly and being seen TIMI-0 or TIMI-1 flow. The electrocardiographic evaluation was done on ECG taken before CA. The occlusion in the first 12 hours was accepted as acute occlusion (AO). Between 12 hours and 1 month subacute occlusion (SAO) and the occlusions after the first month were accepted as chronic total occlusions (CTO). Results: It was found that 177 (54.6%) of total occlusions were acute, 91 (28.1%) were subacute and 56 (17.3%) were chronic. 197 (60.8%) of total occlusions were at proximal RCA, 104 (32.1%) were at mid RCA and 23 (7.1%) are at distal RCA. Mean age is smaller in patients with AO than in patients with SAO or CTO. There were not a statistical significant difference in coronary risk factors between these groups. Almost all of the precordial ST segment deviation are observed in patients with AO. A statistical significant difference is not found between groups of proximal, middle and distal RCA occlusion in terms of clinical diagnosis, demographic and angiographic data. Although there was found significant difference between these groups according to ST segment deviation at precordial V1-V3 derivation, there was not found significant difference for ST segment deviation at V4-V6 derivations. While the ratio of ST segment depression at precordial V1-V3 derivations increase from proximal to distal in significant degree, at V4-V6 derivation. At AO of RCA, the ratio of ST segment elevation at precordial V1-V3 derivations are in orderly 13%, 7.3%, 13.6%. All of these ST segment elevations are observed at proximal and mid RCA occlusions. Conclusions: Precordial ST segment deviations independently from all possible effects on ECG like left CAD result mostly from acute occlusion of RCA. Precordial ST segment deviations are not observed in chronic total occlusion of RCA. While precordial ST segment depression is mostly formed in distal RCA occlusions, precordial ST segment elevation which is rarely seen when compared with precordial ST depression is formed in proximal part of RCA and only in RCA’s acute occlusions.
PP-040 THE SUCCESSFUL USE OF ENOXAPARINE IN THE LACK OF BIVALIRUDIN IN A PATIENT WITH CHRONIC LYMHOCYCTIC LEUKEMIA AND THROMBOCYTOPENIA WHO UNDERWENT PERCUTANEOUS CORONARY REVASCULARIZATION Enbiya Aksakal 1 , Taner Ulus 2 , Mustafa Kemal Erol 1 1 Department of Cardiology, Faculty of Medicine, Ataturk University, Erzurum, Turkey
S53
2 Ministry of Health, Erzurum Region Research and Educational Hospital, Department of Cardiology, Erzurum, Turkey
Objective: Chronic lymphocytic leukemia (CLL) is characterized by abnormal hematopoiesis, anemia and thrombocytopenia. Ischemic and bleeding complications are seen more frequently in these patients and the selection of anticoagulant therapy should be made carefully. We present a case with CLL and thrombocytopenia in whom enoxaparine was succesfully used as an anticoagulant in the absence of direct thrombin inhibitors (bivalirudin) during percutaneous coronary intervention (PCI). Case: A 56-year old male patient with angina pectoris for two days was consulted in our department. He had been followed-up with CLL diagnosis in the Hematology department. ECG demonstrated biphasic T wave in V3 derivation. His cardiac biomarkers were normal. Hematologic values were as follows: Hemoglobin, 11.1 g/dL; hematocrit, 33.5%; platelets, 47×103/μL; leukocyte count, 92.9×103/μL, with 70% lymphocytes, 7% neutrophils, 18% monocytes and 3% basophils. The patient was treated with acetylsalicylic acid 1×100 mg, clopidogrel 1×75 mg, metoprolol 1×100 mg, ramipril 1×2.5 mg, atorvastatin 1×40 mg, enoxaparine 2×0.6 cc subcutaneous, intravenous nitrate. Diagnostic cardiac catheterization was performed. It has been found 95% stenosis of the mid portion of the left anterior descending (LAD) artery. The left circumflex artery and the right coronary artery were normal. One bare metal stent was succesfully deployed in the mid portion of the LAD. Control angiogram demonstrated 0% residual stenosis. Glycoprotein IIb/IIIa inhibitors were not begun to the patient because of the increased hemorrhagic risk. Bivalirudin could not have begun because these drugs were not available in our country. Enoxaparine 2×0.6 cc was continued subcutaneous for two days after the procedure. Serial platelet counts were measured after the procedure and those did not decrease. The patient was followed-up for two days after the procedure and it was not observed angina pectoris or any ischemic complications. Major/minor bleeding was not happened in the femoral region or any site of the body. Discussion/Conclusion: It has been suggested that bivalirudin therapy may effective and safe in patients with CLL and thrombocytopenia during PCI. However, there is no data related to anticoagulant therapy which should be applicated in PCI in the condition of the lack of bivalirudin in such patients. In our case, we used enoxaparine as anticoagulant during PCI because direct thrombin inhibitors were not available in our country. This case suggests enoxaparine therapy together with acetylsalicylic acid and clopidogrel may be effective and safe in the lack of bivalirudin during succesful PCI in a patient with CLL and thrombocytopenia.
PP-041 METHYLENE TETRAHYDROFOLATE REDUCTASE C677T HOMOZIGOT AND FACTOR V LEIDEN HETEROZYGOT MUTATION IN A YOUNG MALE WITH MYOCARDIAL INFARCTION Aysen Helvaci, Ayse Sinangil Arar, Besime Copur, Neslihan Ozsoy 2nd Clinic for Internal Disease, Okmeydani Education and Research Hospital, Istanbul, Turkey Objective: Methylene Tetrahydrofolate reductase is an important factor which is responsible for hyperhomocysteinemia. It has been identified as an independent risk factor hyperhomocysteinemia for atherosclerosis, although the pathological mechanism of this risk is not fully understood. Factor V Leiden is the most common risk factor for venous thrombosis but the relationship between this genetic defect and arterial disease is still unresolved. Methods: A 27 years old young male, admitted to our clinic with acute myocardial infarction who hadn’t any traditional risk factor for coronary heart disease. In laboratory findings; two genetic defects were found responsible and the other risk factor were researched. One of them was methylene tetrahydrofolate reductase deficiency, the other one was heterozygot factor V Leiden mutation. Results: Our patient’s diagnosis was acute inferior posterior lateral infarction with ST elevation when he admitted to coronary care unit. Patient was performed with tissue type plasminogen activator. We didn’t consider to perform angiography because the patient was admitted to our clinic, four hours after the chest pain and coronary angiography couldn’t be made in our center. Coronary angiography had been performed elective condition to him. Osteal LAD 40-50%, mid LAD 30%, Cx proximal 30%, RCA total stenosis was detected in his coronary angiography. Homocysteine levels 20.50 micromol/L was found to be high. Homocysteine level and the relatives of the patient due to factor V Leiden mutation has been scanned.
is a rare condition which may cause acute coronary syndromes. Reported incidence was 0.1%. Approximately three-fourths of the cases were women with a predilection to occur in LAD, whereas right coronary artery lesions predominate in men, in contrast to our case. Classically, the patients are divided into three groups: a peripartum, atherosclerotic and idiopathic group. However several theories have been postulated; the exact pathophysiologic mechanism has not been fully clarified yet. It is thought to be the consequence of an intramural hematoma of a coronary artery, resulting in a false lumen which compresses the true lumen, with subsequent myocardial ischemia. The clinical presentation of patients depends on the extent and severity of the dissection, and ranges from unstable angina to sudden cardiac death. The major diagnostic tool is coronary angiography; and if necessary it may be supported by intravascular ultrasound. Treatment should be individualized. Conservative approach, primary percutaneous coronary intervention, coronary artery by-pass surgery is current treatment options.
PP-039 EVALUATION OF PRECORDIAL ST SEGMENT DEVIATIONS IN ACUTE AND CHRONIC TOTAL OCCLUSIONS OF RIGHT CORONARY ARTERY Mehmet Emin Kalkan, Mahmut Acikel, Sakir Arslan, Enbiya Aksakal, Serdar Sevimli, Fuat Gundogdu, Hakan Tas, Eftal Murat Bakirci Department of Cardiology, Faculty of Medicine, Ataturk University, Erzurum, Turkey Objective: The aim of this study was to examine the patients who have acute, subacute and chronic right coronary artery (RCA) total occlusions but normal left coronary arteries. Additionally, the relation between precordial ST segment deviation and the level of total occlusion at RCA were examined. Methods: This study, retrospectively, were performed with 324 patients that were chosen between consecutive 23922 people applied coronary angiography. Total occlusion is determined as ceasing course of coronary artery abruptly and being seen TIMI-0 or TIMI-1 flow. The electrocardiographic evaluation was done on ECG taken before CA. The occlusion in the first 12 hours was accepted as acute occlusion (AO). Between 12 hours and 1 month subacute occlusion (SAO) and the occlusions after the first month were accepted as chronic total occlusions (CTO). Results: It was found that 177 (54.6%) of total occlusions were acute, 91 (28.1%) were subacute and 56 (17.3%) were chronic. 197 (60.8%) of total occlusions were at proximal RCA, 104 (32.1%) were at mid RCA and 23 (7.1%) are at distal RCA. Mean age is smaller in patients with AO than in patients with SAO or CTO. There were not a statistical significant difference in coronary risk factors between these groups. Almost all of the precordial ST segment deviation are observed in patients with AO. A statistical significant difference is not found between groups of proximal, middle and distal RCA occlusion in terms of clinical diagnosis, demographic and angiographic data. Although there was found significant difference between these groups according to ST segment deviation at precordial V1-V3 derivation, there was not found significant difference for ST segment deviation at V4-V6 derivations. While the ratio of ST segment depression at precordial V1-V3 derivations increase from proximal to distal in significant degree, at V4-V6 derivation. At AO of RCA, the ratio of ST segment elevation at precordial V1-V3 derivations are in orderly 13%, 7.3%, 13.6%. All of these ST segment elevations are observed at proximal and mid RCA occlusions. Conclusions: Precordial ST segment deviations independently from all possible effects on ECG like left CAD result mostly from acute occlusion of RCA. Precordial ST segment deviations are not observed in chronic total occlusion of RCA. While precordial ST segment depression is mostly formed in distal RCA occlusions, precordial ST segment elevation which is rarely seen when compared with precordial ST depression is formed in proximal part of RCA and only in RCA’s acute occlusions.
PP-040 THE SUCCESSFUL USE OF ENOXAPARINE IN THE LACK OF BIVALIRUDIN IN A PATIENT WITH CHRONIC LYMHOCYCTIC LEUKEMIA AND THROMBOCYTOPENIA WHO UNDERWENT PERCUTANEOUS CORONARY REVASCULARIZATION Enbiya Aksakal 1 , Taner Ulus 2 , Mustafa Kemal Erol 1 1 Department of Cardiology, Faculty of Medicine, Ataturk University, Erzurum, Turkey
S53
2 Ministry of Health, Erzurum Region Research and Educational Hospital, Department of Cardiology, Erzurum, Turkey
Objective: Chronic lymphocytic leukemia (CLL) is characterized by abnormal hematopoiesis, anemia and thrombocytopenia. Ischemic and bleeding complications are seen more frequently in these patients and the selection of anticoagulant therapy should be made carefully. We present a case with CLL and thrombocytopenia in whom enoxaparine was succesfully used as an anticoagulant in the absence of direct thrombin inhibitors (bivalirudin) during percutaneous coronary intervention (PCI). Case: A 56-year old male patient with angina pectoris for two days was consulted in our department. He had been followed-up with CLL diagnosis in the Hematology department. ECG demonstrated biphasic T wave in V3 derivation. His cardiac biomarkers were normal. Hematologic values were as follows: Hemoglobin, 11.1 g/dL; hematocrit, 33.5%; platelets, 47×103/μL; leukocyte count, 92.9×103/μL, with 70% lymphocytes, 7% neutrophils, 18% monocytes and 3% basophils. The patient was treated with acetylsalicylic acid 1×100 mg, clopidogrel 1×75 mg, metoprolol 1×100 mg, ramipril 1×2.5 mg, atorvastatin 1×40 mg, enoxaparine 2×0.6 cc subcutaneous, intravenous nitrate. Diagnostic cardiac catheterization was performed. It has been found 95% stenosis of the mid portion of the left anterior descending (LAD) artery. The left circumflex artery and the right coronary artery were normal. One bare metal stent was succesfully deployed in the mid portion of the LAD. Control angiogram demonstrated 0% residual stenosis. Glycoprotein IIb/IIIa inhibitors were not begun to the patient because of the increased hemorrhagic risk. Bivalirudin could not have begun because these drugs were not available in our country. Enoxaparine 2×0.6 cc was continued subcutaneous for two days after the procedure. Serial platelet counts were measured after the procedure and those did not decrease. The patient was followed-up for two days after the procedure and it was not observed angina pectoris or any ischemic complications. Major/minor bleeding was not happened in the femoral region or any site of the body. Discussion/Conclusion: It has been suggested that bivalirudin therapy may effective and safe in patients with CLL and thrombocytopenia during PCI. However, there is no data related to anticoagulant therapy which should be applicated in PCI in the condition of the lack of bivalirudin in such patients. In our case, we used enoxaparine as anticoagulant during PCI because direct thrombin inhibitors were not available in our country. This case suggests enoxaparine therapy together with acetylsalicylic acid and clopidogrel may be effective and safe in the lack of bivalirudin during succesful PCI in a patient with CLL and thrombocytopenia.
PP-041 METHYLENE TETRAHYDROFOLATE REDUCTASE C677T HOMOZIGOT AND FACTOR V LEIDEN HETEROZYGOT MUTATION IN A YOUNG MALE WITH MYOCARDIAL INFARCTION Aysen Helvaci, Ayse Sinangil Arar, Besime Copur, Neslihan Ozsoy 2nd Clinic for Internal Disease, Okmeydani Education and Research Hospital, Istanbul, Turkey Objective: Methylene Tetrahydrofolate reductase is an important factor which is responsible for hyperhomocysteinemia. It has been identified as an independent risk factor hyperhomocysteinemia for atherosclerosis, although the pathological mechanism of this risk is not fully understood. Factor V Leiden is the most common risk factor for venous thrombosis but the relationship between this genetic defect and arterial disease is still unresolved. Methods: A 27 years old young male, admitted to our clinic with acute myocardial infarction who hadn’t any traditional risk factor for coronary heart disease. In laboratory findings; two genetic defects were found responsible and the other risk factor were researched. One of them was methylene tetrahydrofolate reductase deficiency, the other one was heterozygot factor V Leiden mutation. Results: Our patient’s diagnosis was acute inferior posterior lateral infarction with ST elevation when he admitted to coronary care unit. Patient was performed with tissue type plasminogen activator. We didn’t consider to perform angiography because the patient was admitted to our clinic, four hours after the chest pain and coronary angiography couldn’t be made in our center. Coronary angiography had been performed elective condition to him. Osteal LAD 40-50%, mid LAD 30%, Cx proximal 30%, RCA total stenosis was detected in his coronary angiography. Homocysteine levels 20.50 micromol/L was found to be high. Homocysteine level and the relatives of the patient due to factor V Leiden mutation has been scanned.