Adnan Abaci

Effect of Diabetes Mellitus on Formation of Coronary Collateral Vessels

BACKGROUND Although myocardial ischemia is known to be significantly related to the development of coronary collateral vessels (CCVs), there is considerable variation between patients with ischemic heart disease in the presence of collateral development. The nature of this variability is not well known. Likewise, it remains unclear whether diabetes mellitus (DM) has any effect on CCVs. The aim of this study was to evaluate the effect of DM on CCVs. METHODS AND RESULTS Of the patients who underwent coronary angiography during the interval between March 1, 1993, and June 20, 1998, in our institution, 306 were diabetic. Those patients in whom coronary angiography is normal or severity of coronary artery stenosis is thought not to be sufficient for the development of CCVs (<75%) were excluded from the study. A total of 205 patients (mean age, 59+/-8 years) met the criteria for the DM group. For case-control matching, 205 consecutive nondiabetic patients (mean age, 58+/-9 years) who had >/=1 diseased vessel with >75% stenosis were included in the control group. The CCVs were graded according to the Rentrop scoring system, and the collateral score was calculated by summing the Rentrop numbers of every patient. There was no statistical difference between patients with and without DM in clinical baseline characteristics. The mean number of diseased vessels in the DM group (1.58+/-0.68) was higher than that in the nondiabetic group (1.42+/-0.65, P=0.005). The mean collateral score was 2.41+/-2.20 in the DM group and 2.60+/-2.39 in the control group. After confounding variables were controlled for, the collateral score in the diabetic group was significantly different from that in the nondiabetic group (P=0.034). CONCLUSIONS Our findings suggest that CCV development is poorer in patients with than in patients without DM. Thus, we can speculate that DM is an important factor affecting CCV development.

Prevalence of the metabolic syndrome among Turkish adults.

Objective:To determine prevalence of the metabolic syndrome (MS) in a sample representing Turkish population using United States Adult Treatment Panel-3 guidelines.Design:The study included random samples from both urban and rural populations in the seven geographical regions of Turkey. The population for this analysis were 2108 men (1372 in urban and 736 in rural areas) and 2151 women (1423 in urban and 728 in rural areas) with a mean age of 40.9±14.9 years (range 20–90).Results:The prevalence of the MS diagnosed using the Adult Treatment Panel III criteria was 33.9% (1442 of 4259) and differed significantly in men (28%) and women (39.6%). The prevalence of syndrome increased with age in men, from 10.7% in subjects aged 20–29 years to 49% in those aged over 70 years. The prevalence increased with age in women, from 9.6% in subjects aged 20–29 years to 74.6% in those aged 60–69 years, and decreased to 68.6% in those over 70 years of age. The prevalence of the syndrome was similar in urban (33.8%) and rural (33.9%) population. We found 26.8, 26.4, 19.3, 10.9 and 3.6% of the population had at least 1, 2, 3, 4 or 5 components, respectively. We found 57.2, 32.3 and 10.6% of the subjects with MS had 3, 4 and 5 components, respectively.Conclusions:The prevalence of the MS in the adult Turkish population is very high, especially in women. Our findings have important implications for public health in Turkey.

Effect of Potential Confounding Factors on the Thrombolysis in Myocardial Infarction (TIMI) Trial Frame Count and Its Reproducibility

BACKGROUND The potential factors that introduce variability into TIMI frame count (TFC) have not been systematically investigated. The goal of this study was to determine if nitrate use, dye injection rate, catheter size, the phase of the cardiac cycle in which dye is injected, or heart rate affect the TFC and to investigate the reproducibility of the TFC. METHODS AND RESULTS The dye injection rate was increased 1 mL/s, and angiography was repeated. A coronary angiogram was taken first with an 8F catheter and then with a 6F catheter. After taking angiograms, intracoronary nitrate was given to the patient, and the second angiography was performed. Basal heart rate was increased 20 beats/min, and angiography was repeated. Dye injection was performed at the beginning of systole and diastole. The TFC was not significantly changed by increasing the dye injection rate (P=0.467) or by changing catheter size (P=0.693). Nitrate administration significantly increased the TFC from 26.4+/-11.9 to 32.8+/-13.3 frames (P<0.001). Dye injection at the beginning of diastole significantly decreased the TFC from 30.1+/-8.8 to 24.4+/-7.9 frames (P<0.001) for the left coronary artery and from 24.16+/-4.49 to 21. 24+/-4.45 frames (P<0.001) for the right coronary artery. Increasing heart rate significantly decreased the TFC from 30.4+/-6.1 to 25. 3+/-7.2 frames (P<0.001). Intraobserver and interobserver reproducibility of the TFC was good (mean difference, 1.33+/-1.24 and 2.57+/-1.72 frames, respectively). CONCLUSIONS Nitrate use, heart rate, and the phase of the cardiac cycle in which dye is injected had significant effects on the TFC. Therefore, studies comparing TFC need to consider these factors, and the use of nitrates should be either standardized or randomized.

Preload Dependence of Doppler Tissue Imaging Derived Indexes of Left Ventricular Diastolic Function

Doppler tissue imaging (DTI) has been proposed as a tool for the evaluation of diastolic function. Controversy exists regarding whether DTI measurements are influenced by preload. Changes in the circulating volume associated with hemodialysis result in preload reduction. To determine the influence of preload reduction on DTI and standard pulsed‐Doppler transmitral diastolic velocities, 30 patients (mean age 41 ± 14) with chronic renal insufficiency without overt heart disease were studied by DTI and standard pulsed Doppler before and after hemodialysis. From the apical window, DTI sample volume was placed at the lateral and septal mitral annulus and at the midsegment of lateral and septal myocardial wall of the left ventricle. Peak early diastolic annular and myocardial, and peak late diastolic annular and myocardial velocities were measured. Transmitral peak early and late diastolic velocities were also recorded by standard pulsed Doppler. The peak velocity of early diastolic mitral flow decreased from 100 ± 30 to 85 ± 34 cm/s (P < 0.001) after hemodialysis. Hemodialysis elicited marked reduction in early diastolic lateral mitral annular and midlateral myocardial velocities (6.9 ± 3.2 to 6.3 ± 2.9 cm/s, P < 0.04 and 6.7 ± 0.3 to 5.5 ± 2 cm/s, P < 0.001, respectively). Early diastolic, septal mitral annular, and midseptal myocardial velocities were also significantly decreased (5.8 ± 2.8 to 4.6 ± 2 cm/s, P < 0.006 and 6.2 ± 2 to 5.1 ± 1 cm/s, P < 0.008, respectively). Late diastolic mitral annular and myocardial velocities did not change. It is concluded that early diastolic mitral annular and myocardial velocities are affected by acute preload reduction. It is necessary to consider preload when diastolic function is assessed by DTI.

Short and long term complications of device closure of atrial septal defect and patent foramen ovale: Meta-analysis of 28,142 patients from 203 studies

Device closure of atrial septal defect (ASD) and patent foramen ovale (PFO) are both associated with short‐ and long‐term complications. Our knowledge of the complication rates of ASD and PFO closure is limited. Our objective was to review the peri‐procedural and long‐term complications of ASD and PFO closure.

Coronary heart disease is associated with mean platelet volume in type 2 diabetic patients

Background: Mean platelet volume (MPV) is an indicator of platelet activation which is a central process in the pathophysiology of coronary heart disease (CHD). The aim of the study was twofold; first to determine whether MPV values is increased in patients with DM, and secondly to evaluate the relation between diabetic complications and MPV. Methods: The study population included 258 patients divided into two groups. Group A composed of 158 type 2 diabetic patients with coexistent coronary artery disease (stenotic lesions of 50%) (78 women, 80 men; mean age 53.9_10.8; mean diabetes duration 13.1_6.0). One hundred subjects (48 women, 52 men; mean age 53.9_11) without type 2 diabetes with normal coronary angiographies were taken as the control group (group B). To evaluate the extension of CHD, Gensini scoring system was used. Results: The MPV was significantly different in the patient group compared to the controls (9.79 ± 1.5 fl vs 8.3 ± 0.9 fl, P<0.001). The existence of CHD was associated with MPV with odds ratio (95% CI) of 2.31 (1.55–4.42, p50.001). Conclusion: We have found that diabetic patients with coronary heart disease have significantly higher MPV values compared to control subjects without diabetes and with angiographically normal coronary arteries.

Association of serum total bilirubin level with severity of coronary atherosclerosis is linked to systemic inflammation.

OBJECTIVE Although cardiovascular protective action of bilirubin has been attributed to its antioxidant effect, there was scarce data regarding the anti-inflammatory properties. Herein, we aimed to assess the relationship between serum total bilirubin level and severity of coronary artery disease (CAD) in association with the direct inflammatory marker such as C-reactive protein (CRP), the other indirect markers included in inflammation process such as neutrophil to lymphocyte ratio (NLR) and red cell distribution width (RDW) in patients with stable CAD. METHODS Angiographic data of 1501 patients were analyzed in this retrospective cross-sectional study. Patients were categorized according to Gensini scores as control, mild CAD and severe CAD groups. The association of clinical and laboratory parameters with the severity of CAD were determined by multivariable linear regression analysis. RESULTS Total bilirubin level in the control group was significantly higher than those of the other groups. After multivariable linear regression analysis total bilirubin [β=-3.131 (-4.481, -1.782), p<0.001] was significantly associated with the severity of CAD. Futhermore, there was a moderate and significant inverse correlation between serum total bilirubin level and the severity of CAD (r=-0.173, p<0.001), CRP (r=-0.112, p<0.001), NLR (r=-0.070, p=0.026) and RDW (r=-0.074, p=0.027). CONCLUSION Serum total bilirubin level was independently and inversely associated with the severity of coronary atherosclerosis in patients with stable CAD. In addition, total bilirubin level was inversely correlated with CRP, NLR and RDW. These results suggest that besides its already known effect on the oxidative stress, higher serum total bilirubin level may exhibit an anti-inflammatory effect in the coronary atherosclerotic process.

Value of lead aVR in predicting acute occlusion of proximal left anterior descending coronary artery and in-hospital outcome in ST-elevation myocardial infarction: an electrocardiographic predictor of poor prognosis

BACKGROUND We aimed to investigate the value of ST elevation in lead aVR (ST upward arrow aVR) in predicting the left anterior descending coronary artery (LAD) occlusion site proximal to first septal perforator (S(1)) and its effect on in-hospital outcome in ST-elevation myocardial infarction (STEMI). METHODS The study included 950 patients with STEMI. Patients were divided into 2 groups as aVR(+) and aVR(-) according to the presence of an ST upward arrow aVR of 0.5 mm or greater. RESULTS ST elevation in lead aVR was seen in 155 (16%) patients, and LAD occlusion proximal to S(1) was detected in 52% of patients in the aVR(+) group and in 9% of patients in the aVR(-) group. aVR positivity was associated with higher heart rate, lower systolic blood pressure and ejection fraction, and worse Killip class at the hospital admission. In-hospital mortality was 19% in the aVR(+) group and 5% in the aVR(-) group. aVR positivity was an independent predictor of in-hospital death. CONCLUSION This study revealed that ST upward arrow aVR was not only a good indicator of LAD occlusion proximal to S(1) but also a source of valuable information about in-hospital outcome in patients with STEMI.

Colour tissue Doppler echocardiographic evaluation of right ventricular function in patients with right ventricular infarction.

Objective: This study was undertaken to determine right ventricular (RV) function as assessed by colour Doppler tissue imaging (DTI) in patients with RV infarction. Methods: During the study period, 35 patients were evaluated: 14 patients had an inferior myocardial infarction (MI) with RV infarction and 21 patients had an inferior MI without RV involvement. Twenty age-matched healthy subjects served as controls. The diagnosis of RV infarction was defined by ST segment elevation >0.1 mV in lead V4R. Systolic and early and late diastolic velocities were acquired from the apical four-chamber view at the lateral tricuspid annulus, the septal side of the tricuspid annulus and the RV free mid-wall using colour DTI. Results: Systolic and early diastolic velocities at the lateral tricuspid annulus were significantly reduced in patients with inferior MI with RV infarction compared with those in healthy individuals (7.8 ± 1 vs. 11 ± 2 cm/s, p < 0.002) and patients with inferior MI without RV infarction (7.8 ± 1 vs. 10 ± 1 cm/s, p < 0.002). The late diastolic lateral annular velocity did not differ between the groups. Systolic and early diastolic RV free wall velocities were also significantly decreased in patients with RV infarction compared with those in healthy individuals (7 ± 1 vs. 8.7 ± 1 cm/s, p < 0.01; 6.3 ± 2 vs. 8.7 ± 2 cm/s, p < 0.05, respectively) and patients with inferior MI without RV infarction (7 ± 1 vs. 9 ± 2 cm/s, p < 0.01; 6.3 ± 2 vs. 8.3 ± 2 cm/s, p < 0.05, respectively). Conclusion: The evaluation of tricuspid annular and RV free wall velocities using colour DTI provides a rapid and noninvasive tool for assessing RV function in patients with RV infarction.

Renal dysfunction is the most important predictor of the extent and severity of coronary artery disease in patients with diabetes mellitus.

ObjectivesDiabetic patients tend to have more extensive and diffuse coronary artery disease (CAD) that may contribute to the less favorable outcomes in them. The aim of this study was to elucidate the predictors of the angiographic severity and extent of CAD in patients with diabetes. MethodsA total of 203 diabetic patients (116 men; mean age, 61.9±10.8) who were referred for a first coronary angiogram were included. The extent and severity of CAD was assessed in several ways. The first was a simple classification in one-vessel, two-vessel, and three-vessel disease scoring system. The total numbers of segments with ≥20 and ≥50% stenosis were calculated as CASS 20 and CASS 50 scores, respectively. Hamsten and Gensini scores were also calculated. ResultsOf the 203 patients included in the study, 175 (86.2%) had CAD. Multivariate ordinal logistic regression analysis showed that age (Wald 5.741, P=0.017), glomerular filtration rate (Wald 5.032, P=0.025), previous myocardial infarction (Wald 10.955, P=0.001), and family history of CAD (Wald 7.236, P=0.007) were independent predictors of the severity of CAD, as assessed by the clinical zero-vessel to three-vessel disease scoring system. On stepwise multiple linear regression analysis, glomerular filtration rate was an independent predictor of the CASS 20 (r=−0.221, P=0.004), CASS 50 (r=−0.239, P=0.005), Gensini (r=−0.328, P<0.001), and Hamsten (r=−0.320, P<0.001) scores. Previous myocardial infarction was an independent predictor of the CASS 50 (r=0.355, P<0.001), Gensini (r=0.350, P<0.001), and Hamsten (0.256, P<0.001) scores. Age and sex were independent predictors for the CASS 50 (r=0.174, P=0.039; r=0.172, P=0.016, respectively) and Hamsten (r=0.212, P=0.011; r=0.244, P=0.001, respectively) scores. ConclusionRenal function is one of the most important factors associated with the extent and severity of coronary atherosclerosis, whereas classical coronary risk factors and the degree of metabolic control were not associated with the severity of coronary atherosclerosis in diabetic patients.