Cardiovascular Journal of Africa: Vol 28 No 1 (January/February 2016)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 1, January/February 2017

AFRICA

Patients who were below 18 and above 80 years, with coronary

artery disease, haemodynamic changes, congenital heart disease,

left ventricular ejection fraction below 55%, and those who had

severe valve disease were excluded. The study was approved

by the Trakya University Ethics Board (08.02.2012, Decision

Nr.05/12, Protocol Nr. 201/39).

Age, gender, height, weight, hypertension and diabetes

mellitus status, smoking and alcohol consumption, medications,

electrocardiogram (ECG), lipid profile and creatinine levels were

obtained from the patient files. Body mass index (BMI) was

calculated by dividing the body weight (kg) by the square of

the height (m). Echocardiogram (echo) reports were obtained

from the echo laboratory, coronary artery images from the CAG

laboratory, and 24-hour blood pressure levels were obtained

from the effort-Holter laboratory.

The echo evaluations of the patients were performed using

the Vivid 7 Pro (General Electric Medical Systems, Milwaukee,

Wisconsin). Left ventricular ejection fraction (EF) was calculated

with the M-mode imaging method.

Ambulatory blood pressure follow up was done with the

tension artery Holter device (DMS 300-3A Holter Recorder)

90207 device (Space Labs Inc, Richmond, Washington, USA).

ABPM was performed before hospitalisation, irrespective of the

type and duration of antihypertensive drug therapy. The patients

were recommended to maintain daily activities and to hold the

arms straight during measurement. Blood measurements were

made every 15 minutes between 07:00 and 23:00, and every 20

minutes between 23:00 and 07:00. Using short time intervals,

the 10:00–22:00 interval was accepted as the day-time, and the

24:00–06:00 interval as the night-time period. The recorded data

were evaluated at the end of 24 hours.

Systolic and diastolic blood pressure levels and heart rate

measurements were evaluated for the day and night-time periods.

If the mean systolic and diastolic blood pressure levels decreased

by less than 10% or did not fall, the patient was considered

a non-dipper, and if it decreased by more than 10%, it was

considered dipper hypertension.

9,10

All of the patients had undergone CAG due to a positive

myocardial perfusion ischaemia test. The coronary angiography

procedures had been performed up to one month after the

ABPM. Coronary artery evaluation of the patients was made

using the Philips Integris H 3000 (Eindhoven, The Netherlands)

angiogram device. The presence or absence of coronary artery

disorders was recorded. Patients who had any degree of coronary

artery stenosis or plaques and those who had haemodynamic

changes that may have affected the square counts during the

angiogram were excluded. The TIMI frame count of patients

whose coronary arteries were normal was separately calculated

for all three coronary arteries. Nitrate was not administered to

any patients during the CAG, as it could have affected the results

of the measurements.

Gibson

et al

. were the first to present the TIMI frame count,

or the TIMI square-count method as a simple, productive,

objective and quantitative technique to provide a standard index

for coronary blood flow measurement. They investigated the

angiographic images of the TIMI-4 study.

The TIMI frame count was calculated by an independent

operator (always the same operator), who did not know the

AMBP results. To determine the TIMI frame count following

administration of the opaque material, the ciné-angiographic

square counts seen between the level of the stained coronary

artery ostium and its distal part were added up. The first square

was taken at the moment when an opacification was seen filling

the whole of the coronary artery orifice and moving forward.

The last square was caught at the moment when the dye

reached the standard marker point determined separately for the

three arteries by Gibson

et al.

at the distal part of the vessel.

The prediction points were the distal bifurcation branching point

for the left anterior descending artery (LAD) (whale-tail sign

at bifurcation point), the branchlet separating from the distal

bifurcation at the furtherest point where the artery opacified

after the lesion for the circumflex artery (Cx), and the filling

moment of the posterolateral branchlet after the posterior

descending artery for the right coronary artery (RCA). The

best projection angle was the right anterior oblique or the left

anterior oblique-caudal angle for the LAD and Cx, and the left

anterior oblique-cranial angle for the RCA.

In Gibson and co-workers’ study, the TIMI frame count

for the RCA was 20.4

3.0, the square count for the Cx artery

was 22.2

4.1, and for the LAD, it was 36.2

2.6 (

0.001).

These values were standard measurements when the coronary

angiogram device could take 30 frames/s. If the coronary

angiogram worked at a rate of 12.5 frame/s, to adjust to standard

measurements, the value was multiplied by 2.4. If the coronary

angiogram worked at a rate of 25 frame/s, to adjust to standard

measurements, the value was multiplied by 1.2. If the coronary

angiogram worked at a rate of 15 frame/s, to adjust to standard

measurements, the value was multiplied by two.

For the LAD, the correction for this difference was made by

dividing the square count by 1.7. Therefore, the TIMI square

count corrected for the LAD (cLAD) was determined as 21.1

1.5 squares. The mean TIMI frame count was calculated by

adding three coronary artery TIMI frame counts and dividing

by three.

Statistical analysis

For the descriptive statistics of the data, the mean, standard

deviation and ratios were used. The Kolmogorov–Smirnov test

was used for distribution of the data. Comparison of the means

between the two groups was done using the independent samples

-test. The Chi-squared test was used for analysis of the ratios.

The SPSS 20.0 program was used for the analysis. Statistical

significance was set at

0.05 for all analyses.

Results

Sixty patients (38% female), whose mean age was 52.85

10.42

years, were included in the study. The demographic and clinical data

of the patients are presented in Table 1. The patients were grouped

as dippers (

30) and non-dippers (

30). The demographic

and clinical data of the groups were compared. No significant

differences were found between gender, age, smoking and alcohol

consumption of the dipper and non-dipper patient groups.

The BMI in the non-dipper group (25.47

2.92 kg/m

) was

significantly higher than that of the dippers (23.79

2.81 kg/

) (

0.027). There was no significant difference between

symptoms, hyperlipidaemia and diabetes mellitus between the

dipper and non-dipper groups. Similarly, the use of angiotensin