Ahmet Karagöz

Coronary disease risk curve of serum creatinine is linear in Turkish men, U-shaped in women.

Objectives The highest levels of glomerular filtration rate are associated with increased coronary heart disease (CHD) risk, an issue we investigated in separate sexes in a population prone to metabolic syndrome. Research Methods and Procedures In total, 1948 participants of the Turkish Adult Risk Factor study with available creatinine determinations were studied at a mean 3.4 years’ follow-up. Using quartiles of creatinine, risk in Cox models of incident CHD or the likelihood of combined prevalent and incident CHD was assessed. Results Women in the lowest creatinine quartile demonstrated the lowest risk profile across diverse variables, except showing low high-density lipoprotein cholesterol and average apolipoprotein A-I and lipoprotein (a) concentrations implicating impaired atheroprotective properties. Whereas serum creatinine in men was not significantly associated with 6 proinflammatory variables comprised in linear regression analysis, apolipoprotein A-I and lipoprotein (a) were significant positive covariates in women, the latter tending to negative association in women without metabolic syndrome. In men, the highest (>1.10 mg/dL), compared with the lowest, creatinine quartile significantly predicted CHD risk, at 1.85-fold relative risks, after adjustment for established risk factors. The risk curve in women was U-shaped, the top and bottom quartiles tending to display higher risk (odds ratio, 1.28 [95% confidence interval, 0.91-1.80]) compared with the 2 intermediate quartiles. Conclusions Increasing serum creatinine values are associated strongly and independently with CHD risk in men but not in women in whom the risk curve is U-shaped. The phenomenon of low creatinine levels underlies some hitherto unexplained relevant observations, and low measurements may be attributed to inassayability secondary to involvement in autoimmune activation.

Zolmitriptan-induced acute myocardial infarction.

Triptans are an established treatment for acute migraine attacks. By activating 5HT1B/1D receptors they lead to vasoconstriction of the cerebral blood vessels which are dilated during migraine attacks. Moreover, they reduce secretion of vasoactive peptides and conduction of pain stimuli over the cerebral cortex. In up to 7% of cases of treatment with triptans, thoracic pain occurs, although this is mostly transient, mild and without lasting ischemia. We present the case of a 45 year-old woman with a history of migraine with visual aura since the age of 20. She had no history of diabetes mellitus, hypertension, smoking or any other risk factors for cardiovascular events before she was admitted to our emergency room with typical chest pain. An electrocardiogram revealed anterior myocardial infarction following her monthly dose of oral zolmitriptan. Catherization revealed a normal coronary arterial system. The laboratory indices for cardiac risk were within normal ranges. The patient was advised to avoid triptans permanently on being discharged.

Evaluation of cardiovascular risk in patients with Parkinson disease under levodopa treatment

Background Levodopa is the indispensable choice of medial therapy in patients with Parkinson disease (PD). Since L-dopa treatment was shown to increase serum homocysteine levels, a well-known risk factor for cardiovascular disorders, the patients with PD under L-dopa treatment will be at increased risk for future cardiovascular events. The objective of this study is to evaluate cardiovascular risk in patients with PD under levodopa treatment. Methods The study population consisted of 65 patients with idiopathic PD under L-dopa treatment. The control group included 32 age and gender matched individuals who had no cognitive decline. Echocardiographic measurements, serum homocysteine levels and elastic parameters of the aorta were compared between the patients with PD and controls. Results As an expected feature of L-dopa therapy, the Parkinson group had significantly higher homocystein levels (15.1 ± 3.9 µmol/L vs. 11.5 ± 3.2 µmol/L, P = 0.02). Aortic distensibility was significantly lower in the patients with PD when compared to controls (4.8 ± 1.5 dyn/cm2 vs. 6.2 ± 1.9 dyn/cm2, P = 0.016). Additionally, the patients with PD had higher aortic strain and aortic stiffness index (13.4% ± 6.4% vs. 7.4% ± 3.6%, P < 0.001 and 7.3 ± 1.5 vs. 4.9 ± 1.9, P < 0.001 respectively). Furthermore, serum homocysteine levels were found to be positively correlated with aortic stiffness index and there was a negative correlation between aortic distensibility and levels of serum homocysteine (r = 0.674, P < 0.001; r = −0.602, P < 0.001, respectively). Conclusions The patients with PD under L-dopa treatment have increased aortic stiffness and impaired diastolic function compared to healthy individuals. Elevated serum homocysteine levels may be a possible pathophysiological mechanism.

The effects of dialysis-type on left ventricular function in non-diabetic end-stage renal disease patients

Objective In this study we aimed to investigate a possible difference in left ventricular function in patients undergoing peritoneal dialysis (PD) and haemodialysis (HD) using 2D echocardiography. Methods A total of 84 patients were recruited in the study. Both PD and HD groups consisted of 42 end-stage renal disease patients. Patients with left ventricular ejection fraction (EF) < 50%, diabetes mellitus and coronary artery disease were excluded. Baseline characteristics and conventional tissue Doppler echocardiography parameters were recorded. Left ventricular longitudinal (Ls), circumferential (Cs) and radial strain (R) along with strain rate were also recorded in the speckle-tracking echocardiography. These values were compared between the two groups. Results No significant difference was observed between PD and HD patients, in terms of mean time from diagnosis of chronic kidney disease to initiation of the study, mean time from first dialysis to initiation of the study, left ventricular EF, age, sex and heart rate. Left ventricular hypertrophy was also more frequent in HD group and the patients had a higher left ventricular mass index. Left ventricular global Ls, LSRs, LSRe, LSRa and global Rs, RSRs, RSRe, RSRa were detected to be lower in HD patients. Conclusions Longitudinal and radial left ventricular mechanics were found to be better preserved in patients undergoing peritoneal dialysis when compared to haemodialysis patients. Consequently, it can be concluded that peritoneal dialysis provides better protection on left ventricular systolic function compared to haemodialysis.

Sinus node dysfunction requiring permanent pacemaker implantation in a young adult with Klinefelter syndrome.

Patient: Male, 22 Final Diagnosis: Sinus node dysfunction Symptoms: Bradycardia • lassitude Medication: — Clinical Procedure: Pacemaker implantation Specialty: Cardiology Objective: Unusual clinical course Background: Klinefelter syndrome is the most common genetic cause of male infertility and affects approximately 1 in 500 live births. Although accompanying cardiac disorder is not a specific feature of Klinefelter syndrome, rarely associated anomalies such as mitral valve prolapse, atrial septal defect, ventricular septal defect, tetralogy of Fallot, patent ductus arteriosus, and hypertrophic obstructive cardiomyopathy have been reported. A clear association between Klinefelter syndrome and arrhythmic disorders has not yet been demonstrated. Case Report: We report a case of a sinus node dysfunction that required permanent pacemaker implantation in a young adult with Klinefelter syndrome. The patient was consulted to cardiology clinic due to bradycardia. On physical examination, no cardiac abnormality was detected except for bradycardia. Holter results showed sinus arrhythmia with a minimum heart rate of 33 bpm and maximum of 154 Bpm. There were 3612 ventricular premature beats, 30 ventricular pairs, 804 supraventricular premature beats, 7 supraventricular pairs, and 4 supraventricular runs, the longest of which was 5 beats. The patient had defined dizziness and nausea during Holter monitoring. Electrophysiological study (EPS) was planned because existing findings indicated risk of cardiac syncope. Findings of EPS were interpreted as sinus node dysfunction. A permanent pacemaker implantation was performed and the patient has been free of symptoms since. Conclusions: This concomitance should be kept in mind when examining patients with Klinefelter syndrome with bradycardia and/or syncope. It is easily mistaken for epilepsy, which is a commonly encountered abnormality in Klinefelter syndrome.

Spontaneous hemothorax due to dabigatran use in a patient with atrial fibrillation

A 72-years-old male patient admitted to our clinic with the complaint of increasing dyspnea in the last 1 week. He had a medical history of atrial fibrillation and chronic obstructive pulmonary disease. He had been under treatment of 50 mg metoprolol daily and 110 mg dabigatran twice daily for 1.5 years. There was no respiratory sound on the right lower lung field in anterior and posterior aspect. Dullness and decreased thoracic vibration were prominent on the same lung field. Heart rate was 110 beats/min, respiratory rate was 18/min and oxygen saturation was 93% in the room air. Other systemic examination findings were normal. Moderate pleural effusion was detected in the chest X-ray in the right lung (Fig. 1A). Computed tomography scans of the chest also revealed pleural effusion with lobulated contour and 7 cm in diameter in the right hemithorax (Fig. 2). Laboratory findings were as follows; WBC: 12.6 3 10 (4.6–10.2), HGB: 12.9 g/dL (12.2–18.1), Htc: 40.3% (37.7–53.7), Plt: 256 3 10, CRP: 29 mg/dL, ESR: 86 mm/h, PT: 16.9 s (11– 16), INR: 1.27 (0.8–1.25), APTT: 39.5 s (24–34). Dabigatran was discontinued for 24 h and thoracentesis was performed resulting with drainage of significant hemorrhagic material. Blood count findings of pleural fluid were as follows; HGB: 10.8 g/dL (12.2–18.1), Htc: 32.3% (37.7–53.7). Hemothorax was diagnosed considering the ratio of blood/pleural fluid hematocrit which was above 80%. History of trauma was questioned again. However, the patient did not define any history of trauma. The patients was inserted an 8F pleural catheter (Plastimed-ThoracathVR ). An amount of 1100 cc hemorrhagic material was drained in the first day and 250 cc in the second. In the third day, the amount of the fluid was less than 100 cc and it was light-colored. Control chest X-ray demonstrated complete resolution of the fluid and the drain was removed at the fifth day (Fig. 1B). The patient did not have any other reason that would cause hemorrhage except dabigatran use. Dabigatran and B-blocker were discontinued due to life-threatening hemorrhage in the lungs and acetyl salicylic acid in addition to diltiazem therapy was started at the fifth day. New hemorrhage was not observed under these drugs and the patient was discharged asymptomatically. The most common cause of hemotorax is blunt or penetrating trauma. Spontaneous hemothorax develops in the absence of any traumatic reason and is quite rare. Spontaneous hemothorax often accompanies pneumothorax. It occurs due to rupture of vascularized adhesions between parietal and visceral pleura. Isolated hemothorax often develops secondary to coagulopathies, neoplasms, vascular ruptures and pleural endometriosis (1). The main goal of anticoagulant use is to reduce risk of systemic thromboembolic events and stroke. Warfarin has been used quite effectively for this purpose. However, it is subject to increased risk of bleeding and management of dosing is quite difficult. New oral anticoagulants (rivaroxaban, dabigatran and apixaban) are direct thrombin inhibitors and do not require dose management. Dabigatran was found to be superior to warfarin in terms of stroke and systemic embolism prevention in a study who were followed up for 2 years. Major and minor bleeding rates were observed to be significantly lower in dabigatran group with the dose of 110 mg (2). The literaure includes reports about spontaneous hemothorax due to warfarin use. However, INR value was not in the therapeutic range in these cases and warfarin overdose was the main problem (3, 4). Spontaneous hemotorax cases have also been reported in patients using low molecular weight heparin (5, 6). Likewise, unfractioned heparin has also been reported to cause spontaneous hemothorax (7). Unlike, spontaneous hemothorax due to new oral anticoagulants has not been reported previously. Traetment of spontaneous hemothorax is drainage with large chest tube while urgent surgery may be required in massive cases in addition to blood and fluid replacement. In our case, vital signs were stable. There was no clot in the pleural fluid and a total of 1400 cc hemorrhagic fluid was drained. To our knowledge, our case is the first report of a spontaneous hemotorax due to dabigatran use. Our case was treated nonsurgical therapeutic approach via Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article and have no relevant financial disclosures.

Cardioprotective effects of Viscum album L. ssp. album (Loranthaceae) on isoproterenol-induced heart failure via regulation of the nitric oxide pathway in rats.

Objective: Viscum album L. has favorable cardiovascular effects including antihypertensive and vasorelaxant activity, and the nitric oxide (NO) pathway upregulation has been proposed to be the underlying mechanism. NO also plays an important role in the pathophysiology of heart failure. However, its effects on cardiac systolic function are unclear. Methods: A total of 30 male Wistar albino rats at 12 weeks of age were randomly divided into three groups: control, isoproterenol-induced heart failure group (ISO), and isoproterenol-induced heart failure + V. album treatment group (VA) groups (n=10 in each group). V. album was orally given at a dose of 250 mg/kg/day by gavage. Parameters of heart failure were compared among the groups. Tamhane’s T2 test, paired sample t-test, and Bonferroni methods were used for statistical analysis. Results: V. album resulted in an improvement in all parameters of heart failure including left ventricular diameters (6.34±0.23 mm, 6.98±0.35 mm, and 6.71±0.10 mm for left ventricular end-diastolic diameter in control, ISO, and VA groups, respectively, p<0.05), ejection fraction (73.3±3.1%, 56.7±2.6%, and 65.2±1.5% for control, ISO, and VA groups, respectively, p<0.05), serum NT-proBNP levels, and histopathological changes. V. album treatment resulted in a statistically significant attenuation of increased levels of NO and iNOS (p<0.0001). The levels of hs-CRP were also found to be lower in the VA group compared with the controls and ISO groups (p<0.01). Conclusion: V. album exerted favorable effects on left ventricular function in isoproterenol-induced heart failure rats. Upregulation of the NO pathway seems to be the possible pathophysiological mechanism. Favorable vascular outcomes can also be speculated considering the reduction in serum hs-CRP levels.

Multidetector computed tomographic anatomy of the coronary sinus in patients with supraventricular reentrant tachycardia

BACKGROUND In a number of previous studies it has been observed that coronary sinus (CS) ostium was larger and cannulation was easier in patients with atrioventricular nodal reentrant tachycardia (AVNRT). AIM To investigate the size and morphology of CS in AVNRT patients and compare them to those of atrioventricular reentrant tachycardia (AVRT) patients and a control group using multidetector computed tomography (MDCT), which is a non-invasive technique. METHODS Eighteen consecutive patients with AVNRT who were scheduled for catheter ablation in our institution constituted the study population. Sixteen patients with AVRT and 16 patients without supraventricular arrhythmia who underwent MDCT for other indications comprised the control group. A conventional transthoracic echocardiography was performed to all patients. The diameter of the CS at ostium as well as at 5, 10, and 15 mm inside the CS were measured on MDCT images. The CS was also categorised according to its morphology, as to whether it had a windsock shape or a tubular shape. RESULTS The AVNRT, AVRT and control groups were similar with regard to age, gender, body surface area and echocardiographic parameters. The size of the CS ostium was 10.9 ± 3.0, 11.1 ± 3.9 and 12.5 ± 3.6 mm for the AVNRT, AVRT and control groups, respectively (p = 0.393). There was no significant difference in the size of the CS from the ostium until 15 mm into the CS between the AVNRT, AVRT and control groups. The number of patients with windsock or tubular CS morphology were also similar between the three groups. CONCLUSIONS Contrary to previous reports, the CS size and morphology of patients with AVNRT did not differ from that of AVRT or control patients.

Distinction of hypertriglyceridemic waist phenotype from simple abdominal obesity: interaction with sex hormone-binding globulin levels to confer high coronary risk

ABSTRACT Objective: The associations of total testosterone (TT) and sex hormone-binding globulin (SHBG) with the hypertriglyceridemic waist (HtgW) phenotype and coronary heart disease (CHD) risk have scarcely been examined. We explored such cardiometabolic risk mediations in middle-aged adults. Methods: Participants (n = 1924) in a population-based study were studied by forming categories consisting of abdominal obesity, hypertriglyceridemia, both (HtgW), or none (‘healthy’). Cardiometabolic risk was prospectively analyzed (mean follow-up 5.7 years). Results: With reference to the healthy group, SHBG values in HtgW were significantly lower, alike serum HDL-cholesterol. ApolipoproteinB-containing lipoproteins, fasting glucose and complement C3 levels, inverse to lipoprotein[Lp](a) especially in female participants with HtgW phenotype compared with those in the ‘healthy’ category, suggested the operation of aggregation to Lp(a). Multivariable Cox regression analysis in a model comprising age, waist circumference and systolic blood pressure showed significant protection by SHBG against incident diabetes which tended to be so with TT in men. Sex hormones were not associated with risk of incident CHD or MetS. In another multivariable model, compared to the ‘healthy’ and the hypertriglyceridemia categories, dichotomized high and, in females, low SHBG values within the HtgW category, positively predicted CHD at significant over 2–fold relative risks. Conclusion: HtgW phenotype distinguishes itself from the (virtually neutral) simple abdominal obesity in independently conferring high CHD risk when elevated or reduced SHBG levels interact. Underlying operation of Lp(a) aggregation is suggested.

Volume depletion provided by blood donation alters twist mechanics of the heart: Preload dependency of left ventricular torsion

Abstract Objectives: The crucial role of twisting motion on both left ventricular (LV) contraction and relaxation has been clearly identified. However, the reports studying the association between LV torsion and loading conditions have revealed conflicting outcomes. Previously normal saline infusion was shown to increase LV rotation. Our aim was to test this phenomenon after volume depletion in healthy volunteer blood donors. Design: A total of 26 healthy male volunteers were included in the study. LV end-diastolic and end-systolic diameter, LV ejection fraction, LV diastolic parameters, LV apical and basal rotation and peak systolic LV torsion were measured by speckle-tracking echocardiography before and after 450 mL blood donation. Results: Blood donation led to a significant decrease in end-diastolic LV internal diameter (48.7 ± 0.4 versus 46.4 ± 0.4 mm; p < 0.001) and cardiac output (6.2 ± 1.0 versus 5.1 ± 0.7 L/min; p < 0.001). There was a significant decrease in the magnitude of peak systolic apical rotation (4.4 ± 1.9° versus 2.9 ± 1.5°; p < 0.001) but no change in basal rotation (2.6 ± 1.4° versus 2.7 ± 1.6°; p = 0.81). Peak systolic LV Torsion decreased after blood donation (6.9 ± 1.9° versus 5.7 ± 2.1°; p = 0.028). Conclusions: LV apical rotation and peak systolic LV torsion seem to be preload dependent. Preload reduction provided by 450-mL blood donation decreased LV torsion in healthy male volunteers. Volume dynamics should be taken into account in the evaluation of LV torsion.