Based on the new findings derived from the recent studies, the European Society of Cardiology has updated the guidelines for acute myocardial infarction in patients with ST-segment elevation. New guidelines have been released on November 2008, and compared to the 2003 guidelines, important new recommendations have been made regarding the acute and long term management of patients presenting with ST-segment elevation myocardial infarction. These new recommendations primarily focus on: the need for setting up networks of hospitals with different levels of technology using the same protocol and connected by an efficient ambulance service; the selection of primary percutaneous coronary intervention (PCI) vs. fibrinolytic therapy; the use of antithrombotic co-therapies with both primary PCI and fibrinolysis; timing of angiography in patients not undergoing to primary PCI; secondary prevention in long term management following the myocardial infarction.

Objectives: The significance of T-wave negativity in lead V1 in adults and its relationship with cardiovascular risk factors have not been clarified. This study was designed to determine the prevalence of negative T waves in chest lead V1 in an adult cohort.
Study design: The study included 508 adults (278 males, mean age 51.5±9.7 years; 230 females, mean age 51.2±10.0 years) enrolled in the longitudinal Turkish Adult Risk Factor survey from all geographical regions of Turkey, whose prospective data on the prevalence of coronary heart disease and its risk factors were available for comparative assessment of T-wave groups. Associations of negative T waves were sought in relation to age, sex, cardiovascular risk factors, and coronary heart disease.
Results: The prevalence of T-wave negativity in women was significantly higher than that of men (38.3% vs 7.2%; p<0.001). No age-related differences were found between the two sexes with respect to the presence or absence of negative T waves (p>0.05). Cardiovascular risk factors and cardiometabolic conditions did not differ among men with respect to the T-wave pattern. However, women presenting negative T waves in lead V1 had significantly lower systolic blood pressure (p=0.007) and HDL-cholesterol (p=0.034) values, and a higher incidence of type 2 diabetes (p=0.048) than women with positive T waves.
Conclusion: No convincing explanation could be offered for the significantly higher female predilection for the presence of negative T-waves in lead V1. Negative T waves in lead V1 were not associated with adverse cardiometabolic risks.

Objectives: It has been demonstrated that intracoronary stem cell transplantation may have beneficial effects on left ventricular function and perfusion both in patients with acute and chronic ischemic cardiomyopathy (ICMP). We evaluated the safety and feasibility of intracoronary autologous bone marrow-derived mononuclear stem cell (MSC) implantation in patients with ICMP.
Study design: The study included 15 patients (14 males, 1 female; mean age 49±11 years) with ICMP. All the patients received MSC transplantation via a balloon catheter to the target vessel which had been revascularized by percutaneous coronary intervention and was patent before the procedure. Evaluations were made at baseline and 6, 12, and 18 months after the procedure with complete clinical and laboratory examinations, and by treadmill exercise test, conventional echocardiography, and SPECT imaging.
Results: At six months, left ventricular ejection fraction increased significantly (p=0.001), hypoperfused areas on SPECT images reduced (p=0.002), and both myocardial oxygen consumption (p=0.001) and metabolic equivalents (p=0.001) increased. These beneficial effects of stem cell therapy were also observed at 12 and 18 months. No complications or in-hospital events occurred related with the procedure.
Conclusion: Due to its beneficial effects on heart failure symptoms, left ventricular function, and perfusion, intracoronary stem cell transplantation can be used as an alternative, adjunctive treatment option in patients with ICMP.

Objectives: We investigated the prevalence, distribution, risk factors, and prognosis of coronary artery ectasia (CAE) in patients undergoing coronary angiography for suspected coronary artery disease (CAD).
Study design: Of 4,119 patients undergoing elective coronary angiography between 2003 and 2005, 173 patients (139 males, 34 females; mean age 61±11 years) had CAE, with a prevalence of 4.2%. Distribution of CAE was made according to the classification of Markis et al. The results were compared with those of 145 control patients (115 males, 30 males; mean age 61±10 years) who had CAD but not CAE. Following coronary angiography, treatment was designed as aortocoronary bypass (n=3), percutaneous coronary intervention (n=36), and medical therapy (n=98). The mean follow-up was 34.2±2.5 months.
Results: Among CAE patients, there was a marked male preponderance with 80.3%. Coronary ectasia was isolated in 46 patients (26.6%) and was associated with significant coronary artery stenoses in 127 patients (73.4%). The only significant difference with the control group with respect to baseline features was the higher frequency of hypertension in the CAE group (p=0.002). Coronary ectasia involved a single vessel in 67.1%, two vessels in 24.9%, and three vessels in 8.1%, with the right coronary artery being the most common localization (50.9%). The diameters of ectatic coronary arteries ranged from 3.2 mm to 9.7 mm (mean 5.6 mm). According to the classification of Markis et al., the majority of patients (64.2%) had type IV ectasia. In multiple regression analysis, hypertension was independently associated with CAE (OR: 0.378; 95% CI: 0.211-0.678; p=0.001). Mortality occurred in nine patients (5.2%). The annual mortality rates were 1.5%, 2.1%, and 2.9% with medical therapy, percutaneous coronary intervention, and aortocoronary bypass, respectively.
Conclusion: Our findings suggest that further prospective studies focus on the dependent relationship between hypertension and CAE, and on marked coexistence of CAD and CAE.

Objectives: We investigated whether patients with rheumatic and degenerative heart valve disease (HVD) differed with regard to plasma and tissue oxidative stress index (OSI).
Study design: The study included 56 patients who underwent valve replacement due to rheumatic (n=32; 15 males; mean age 47±10 years) and degenerative (n=24; 13 males; mean age 55±12 years) HVD. Plasma and tissue total oxidative status (TOS) and total antioxidative capacity (TAC) levels were measured and OSI was calculated.
Results: Patients with degenerative HVD had significantly higher age, increased interventricular septum thickness, and higher frequency of aortic stenosis, whereas the incidence of mitral stenosis was higher in patients with rheumatic HVD (p<0.05). Plasma oxidative characteristics did not differ between the two HVD groups (p>0.05). Tissue TAC was significantly lower in patients with rheumatic HVD (p=0.027), whereas tissue TOS and OSI were similar between the two HVD groups (p>0.05). In bivariate analysis, plasma OSI did not show any correlation with clinical, laboratory, and echocardiographic variables (p>0.05).
Conclusion: Our data show that plasma and tissue OSI levels are similar in patients with rheumatic and degenerative HVD.

Objectives: This study sought to investigate the role of left atrial diameter in predicting adverse clinical events in patients with hypertrophic cardiomyopathy (HCM).
Study design: The study prospectively included 83 consecutive patients (45 males, 38 females; mean age 47±17 years) with HCM. Admission transthoracic echocardiograms were obtained. Left atrial diameter was measured at end-systole from the parasternal long-axis view and left atrial diameter index (LADI) was derived (left atrial diameter/body surface area). Clinical endpoints were defined as cardiovascular death and/or worsening heart failure symptoms. The mean follow-up period was 622±366 days (range 14 to 1142 days).
Results: Adverse clinical events were seen in 27 patients (32.5%), including two deaths and deterioration in NYHA functional class (n=25). Based on the median LADI of 2.5 cm/m2, patients whose LADI was ≥2.5 cm/m2 had a higher value of log NT-proBNP, increased maximal wall thickness, and higher rates of adverse events, advanced NYHA functional class, significant mitral regurgitation, and left ventricular outflow tract obstruction. In ROC analysis, the cutoff value of 2.2 cm/m2 for LADI predicted adverse events with 89% sensitivity, 34% specificity, 84% negative and 38% positive predictive values. Kaplan-Meier analysis showed that patients with LADI <2.2 cm/m2 had a significantly lower rate of adverse events. In binary logistic regression, predictors of increased LADI were female sex, advanced NYHA functional class, log NT-proBNP, maximal wall thickness, significant mitral regurgitation, and left ventricular outflow tract obstruction. However, log NT-proBNP was the only independent predictor of increased LADI in multivariate regression analysis (OR= 2.1; 95% CI: 1.3-3.4; p=0.004).
Conclusion: Our data suggest that LADI may be used as a powerful predictor of adverse clinical events in patients with HCM.

Cardiac metastasis of Ewing’s sarcoma is rare. A 22-year-old woman was admitted with complaints of palpitation and fatigue on exertion. She had a seven-year history of radical right tibial resection for Ewing’s sarcoma and was also receiving chemotherapy for lung metastasis of Ewing’s sarcoma. Both transthoracic and transesophageal echocardiography demonstrated a single, large (3x3.5 cm) inhomogeneous mass located in the free wall of the right ventricle. To differentiate the mass from a massive thrombus, contrast-enhanced magnetic resonance imaging was performed. The mass showed partial contrast enhancement, suggesting a malignant metastatic mass. Surgical resection was not considered due to accompanying lung metastasis and potentially poor outcome of the operation.

Myxoma is the most common primary tumor of the heart. Although cardiac myxomas are histologically benign, they may be a source of emboli and cause intracardiac obstruction resulting in acute myocardial infarction. A 38-year-old male patient was admitted with a clinical presentation of acute coronary syndrome and angina of six-month history. The electrocardiogram showed sinus rhythm and pathological Q waves in leads D2-3 and aVF. Two-dimensional echocardiography showed a large immobile mass, 6.8x3.4 cm in size, in the left atrium, causing obstruction of the left ventricular inflow. The mass protruded through the mitral valve into the left ventricle. There was also inferior wall akinesia. Selective coronary angiography showed normal coronary arteries, but demonstrated marked neovascularization of the left atrial mass which was supplied by the left circumflex artery originating from the right coronary cusp. Ventriculography showed inferior wall akinesia. The patient was immediately submitted to cardiac surgery. The mass was resected and histologic diagnosis was atrial myxoma. The patient had an uneventful postoperative course.

Coronary arteriovenous fistula is an uncommon anomaly, occurring as an incidental finding in 0,1% to 0,2% of coronary angiograms. We describe a symptomatic patient with the proximal part of the left circumflex artery connected to the pulmonary artery through a fistula, as an unusual case.

A 26-year-old male patient presented with complaints of pain, dyspnea, and hemoptysis of one-week history, while on oral anticoagulation treatment that had been started two years before upon the diagnosis of pulmonary thromboembolism. Transthoracic echocardiography showed two mass lesions in the right atrium and inferior vena cava, measuring 3.5x3 cm and 1.5x1 cm, respectively. The possibility of vegetation or secondary cardiac tumor was excluded by further examinations and, considering consistent oral anticoagulation, no other cause could be determined related to thrombus formation. Multiple cardiac myxomas were thought for the differential diagnosis and the patient underwent surgery. Histopathologic diagnosis of both masses was thrombus.

Pulmonary Langerhans cell granulomatosis (PLCG) is a smoking-related interstitial lung disease characterized by hyperinflation and/or obstructive pulmonary disease. Pulmonary hypertension is a late complication of advanced pulmonary disease and often portends a poor prognosis. A 24-year-old male patient who had been receiving diltiazem and corticosteroid treatment with the diagnosis of PLCG for four years was examined by the cardiology clinic due to dyspnea and deterioration in his functional capacity. He was in New York Heart Association class III. The electrocardiogram showed sinus rhythm and right bundle branch block. Systolic pulmonary artery pressure (SPAP) was estimated as 80 mmHg with continuous-wave Doppler echocardiography. During right heart catheterization, SPAP was 70 mmHg and the mean pulmonary artery pressure (MPAP) was 44 mmHg. Vascular pulmonary reactivity test with adenosine did not result in a significant change in MPAP. Based on these findings, medical treatment was scheduled for the patient.

Myocardial bridge is a cluster of myocardial fibers crossing over the epicardial coronary arteries at a distance. It is most frequently seen on the left anterior descending artery. Involvement of the left circumflex coronary artery is very rare. A 63-year-old man presented with chest pain radiating to the left shoulder. Physical examination was normal. The electrocardiogram showed slight lateral ST-segment changes. Treadmill electrocardiography revealed significant lateral ST and T wave changes. Coronary angiography showed normal coronary arteries except for significant systolic narrowing of the mid-circumflex artery after the first obtuse marginal branch. The patient was discharged with beta-blocker therapy. He had no recurrent chest pain during eight months of follow-up.