Alim Erdem

The effect of metabolic syndrome on heart rate turbulence in non-diabetic patients.

BACKGROUND Metabolic syndrome (MetS), which includes a cluster of risk factors, is being increasingly recognized as a new risk factor for cardiovascular disease. Heart rate turbulence (HRT) is a Holter-based non-invasive method for detecting cardiac autonomic imbalance and is an independent, powerful predictor of cardiac arrhythmias and sudden cardiac death in different patient groups. This study evaluated the effect of MetS on HRT in non-diabetic patients. METHODS This study included 80 non-diabetic MetS subjects and 50 healthy subjects. All 130 subjects underwent a 24-h ambulatory Holter electrocardiogram recording. Two indices of HRT were analyzed: turbulence onset (TO) and turbulence slope (TS). HRT values were classified into 3 categories for risk stratification: 1) Category 0, TO and TS were normal; 2) Category 1, either TO or TS was abnormal; 3) Category 2, both TO and TS were abnormal. RESULTS When we compared MetS rates in the HRT risk stratification groups, there were significant differences for all groups as compared with the controls (Category 0 = MetS 28.8%, n = 15, Control 71.2%, n = 37, p 〈 0.001; Category 1 = MetS 80.8%, n = 42, Control 19.2%, n = 10, p 〈 0.001; Category 2 = MetS 88.5%, n = 23, Control 11.5%, n = 3, p 〈 0.001). In addition, TO and TS abnormalities were correlated with the number of MetS components (r = 0.608, p 〈 0.001; r = -0.388, p 〈 0.001, respectively). CONCLUSIONS To our knowledge, this is the first study to establish a relationship between HRT and MetS. These findings suggest that MetS adversely affects HRT scores. In addition, the number of MetS components is related to impaired HRT scores.

Detection of subclinical atrial dysfunction by two-dimensional echocardiography in patients with overt hyperthyroidism.

BACKGROUND Hyperthyroidism is an important cardiovascular risk factor in the development of atrial fibrillation and heart failure. Increased atrial electromechanical intervals are used to predict atrial fibrillation, measured by tissue Doppler imaging (TDI). AIMS To evaluate atrial electromechanical delay (EMD) and left atrial (LA) mechanical function in patients with overt hyperthyroidism. METHODS Thirty-four patients with overt hyperthyroidism and 34 controls were included. A diagnosis of overt hyperthyroidism was reached with decreased serum thyroid-stimulating hormone (TSH) and increased free T4 (fT4) concentrations. Using TDI, atrial electromechanical coupling (PA) was obtained from the lateral mitral annulus (PA lateral), septal mitral annulus (PA septum) and right ventricular tricuspid annulus (PA tricuspid). LA volumes (maximum, minimum and presystolic) were measured by the disks method in apical four-chamber view and indexed to body surface area. LA active and passive emptying volumes and fractions were calculated. RESULTS LA diameter was significantly higher in hyperthyroid patients (P=0.001). LA passive emptying volume and fraction were significantly decreased in hyperthyroid patients (P=0.038 and P<0.001). LA active emptying volume and fraction were significantly increased in hyperthyroid patients (P<0.001 and P<0.001). Left and right intra-atrial (PA lateral-PA septum and PA septum-PA tricuspid) and interatrial (PA lateral-PA tricuspid) EMDs were significantly higher in hyperthyroid patients (29.2 ± 4.4 vs 18.1 ± 2.6, P<0.001; 18.7 ± 4.3 vs 10.6 ± 2.0, P<0.001; and 10.5 ± 2.9 vs 7.1 ± 1.2, P<0.001, respectively). Stepwise linear regression analysis demonstrated that fT4 and TSH concentrations were independent predictors of interatrial EMD (β=0.436, P<0.001 and β=-0.310, P=0.005, respectively). CONCLUSION This study showed prolonged atrial electromechanical intervals and impaired LA mechanical function in patients with overt hyperthyroidism, which may be an early sign of subclinical cardiac involvement and dysrhythmias in overt hyperthyroidism.

Cardiac Autonomic Function Measured by Heart Rate Variability and Turbulence in Pre-hypertensive Subjects

Non-dipping blood pressure pattern was shown to be associated with increased cardiovascular events. In addition, cardiac autonomic dysfunction was found to be associated with non-dipper phenomenon. In this study, we aimed to evaluate the cardiac autonomic functions in dipper and non-dipper pre-hypertensive subjects. A total of 65 pre-hypertensive subjects were enrolled in this study. They were divided into two groups as non-dippers (40 subjects, 52% female) and dippers (25 subjects, 52.5% female). Cardiac autonomic functions of the two groups were compared with the aid of heart rate variability, heart rate turbulence (HRT), atrial premature contractions (APCs), ventricular premature contractions (VPCs), and mean heart rate (MHR). There was no significant difference between non-dippers and dippers in basal characteristics. The two parameters of HRT, turbulence onset and turbulence slope, were found to be significantly abnormal in non-dippers than in dippers (P < .011 and P < .002, respectively). Heart rate variability parameters, including SDNN, SDANN, RMSSD, and pNN50, were found to be similar in dipper and non-dipper pre-hypertensive subjects (P < .998, P < .453, P < .205, and P < .788, respectively). APCs, VPCs, and MHR were compared, and there were statistical differences between the groups (APCs 5.80 ± 4.55, 9.14 ± 7.33, P < .024; VPCs 8.48 ± 8.83, 13.23 ± 9.68, P < .044; and MHR 70.16 ± 11.08, 76.26 ± 11.31, P < .035; respectively). This study demonstrated a possible cardiac autonomic dysfunction in pre-hypertensive subjects with non-dipper pattern. This may be a basis for future studies related to pre-hypertension and non-dipping BP pattern.

Electrophysiological validation of total atrial conduction time measurement by tissue doppler echocardiography according to age and sex in healthy adults.

We sought to validate total atrial conduction time (TACT) measurement via tissue Doppler imaging (TDI) by comparing the electrophysiological study (EPS) measurements of healthy subjects, according to age and sex.

Cardiac autonomic function in healthy young smokers.

The present study examined the heart rate turbulence (HRT) and heart rate variability (HRV) parameters in healthy young smokers (<40 years) to assess the effects of smoking on cardiac autonomic function. The study included 75 smokers with a history of habitual smoking for at least 1 year (41 males and 34 females; mean age, 29.3 ± 7.3 years) and 30 nonsmokers (hospital staff; 16 males and 14 females; mean age, 29.0 ± 6.1 years). Addiction to smoking was evaluated using the modified Fagerström test for nicotine-dependence index (NDI). HRT, HRV, basic clinical and echocardiographic, and Holter test parameters were compared between groups. No significant differences between the two groups were found in the basic clinical and echocardiographic variables. Turbulence onset (TO) was significantly higher in the smoking group than in the controls, and turbulence slope was significantly lower in the smokers, than in the controls (p < 0.05). Standard deviation of all normal-to-normal (NN) interval index (SDNNI) was the only HRV parameter that was significantly different between the smoking and control groups (p < 0.05). The NDI was positively correlated with the TO (p < 0.05). Smoking impairs the baroregulatory function in healthy young smokers, particularly the HRT parameters and SDNNI. Our findings highlight the importance of complete smoking cessation.

The diagnostic significance of NT-proBNP and troponin I in emergency department patients presenting with palpitations

OBJECTIVE: This prospective study investigated the diagnostic significance of the N-terminal pro-brain natriuretic (NT-proBNP) and troponin I peptides in emergency department patients presenting with palpitations. METHODS: Two groups of patients with palpitations but without documented supraventricular tachycardia were compared: a group with supraventricular tachycardia (n = 49) and a control group (n = 47). Both groups were diagnosed using electrophysiological studies during the study period. Blood samples were obtained from all of the patients to determine the NT-proBNP and troponin I levels within the first hour following arrival in the emergency department. RESULT: The mean NT-proBNP levels were 207.74±197.11 in supraventricular tachyarrhythmia group and 39.99±32.83 pg/mL in control group (p<0.001). To predict supraventricular tachycardia, the optimum NT-proBNP threshold was 61.15 pg/mL, as defined by the receiver operating characteristic (ROC) curve, with a non-significant area under the ROC curve of 0.920 (95% CI, 0.86-0.97, p<0.001). The NT-proBNP cut-off for diagnosing supraventricular tachycardia had 81.6% sensitivity and 91.5% specificity. Supraventricular tachycardia was significantly more frequent in the patients with NT-proBNP levels ≥61.15 pg/mL (n = 44, 90.9%, p>0.001). The mean troponin I levels were 0.17±0.56 and 0.01±0.06 pg/mL for the patients with and without supraventricular tachycardia, respectively (p<0.05). Of the 96 patients, 21 (21.87%) had troponin I levels ≥0.01: 2 (4.25%) in the control group and 19 (38.77%) in the supraventricular tachycardia group (p<0.001). CONCLUSION: Troponin I and, in particular, NT-proBNP peptide were helpful for differentiating supraventricular tachycardia from non- supraventricular tachycardia palpitations. Further randomized, large, multicenter trials are needed to define the benefit and diagnostic role of NT-proBNP and troponin I in the management algorithm of patients presenting with palpitations in emergency departments.

The relationship between cardiac autonomic functions and left ventricular diastolic dysfunctions in metabolic syndrome.

With great interest, we have read the recent manuscript by Hwang et al. [1] regarding the association Metabolic syndrome (MetS) and insulin resistance (IR) with abnormal left ventricular diastolic function and structure independent of blood pressure and fasting plasma glucose level. The authors have very clearly discussed the association of MetS and IR with left ventricular diastolic dysfunction (LVDD). In addition, we aimed to emphasize that the independent association of MetS and IR with left ventricular diastolic function leads to the cardiac rhythm disturbances without other cardiac conditions. Metabolic syndrome (MetS) consists of a group of cardiovascular risk factors. In addition, previous studies showed that MS has impacts on left ventricular geometry and function, which are potent bioassays of preclinical cardiovascular disease [2,3]. Despite the ties to impact on LV geometry and function, insulin resistance, elevated blood pressure, and abdominal obesity, the main pathophysiological mechanism underlying the increased cardiovascular risk is unclear. Previous studies showed that LVDD is associatedwith ventricular and atrial arrhythmias. Although it was previously thought that LVDD was just a passive conduit, it is now well-known that optimal LV diastolic function owns a valuable role also in cardiac autonomic dysfunction [4–6]. It was established that LVDD is a predictive marker for cardiac arrhythmias [7]. Studies have shown that cardiac autonomic dysfunction plays an essential role in the development of cardiovascular arrhythmic diseases in MetS patients [8,9]. However, there are only few studies evaluating the effects of Mets on cardiac autonomic functions. In our previous studywe aimed to discover the relationship betweenMetS and cardiac autonomic dysfunction as detected by heart rate turbulence (HRT), in MetS patients without coronary artery diseases and diabetes mellitus [10]. The impairedHRTscores are reported as a usefulmarker for cardiac autonomicdysfunction [11].We found thatMetSadverselyaffects HRT scores. Cardiac autonomic dysfunction in patients with MetS can be showed using different parameters, such as heart rate variability and heart rate recovery [9,12]. In addition to our result, the number of MetS components is related to impairedHRTscores.We found that, therewere a strong positive correlation between the numbers of MetS components and a moderate negative correlation between the number of MetS components and HRT scores were also detected. Similarly, Protorov and Glukhovsky showed a significant correlation between arrhythmias and the number of MetS components. In conclusion, previous studies revealed that cardiac autonomic functions are significantly impaired in MetS patients in accordance with the findings of Hwang et al. [1]. We believe that the relationship betweenMetS and CV disease development is also related to cardiac autonomic dysfunction. We hope that the above-mentioned items would add to the value of the well-written manuscript of Hwang et al., which reveals the association of MetS with abnormal left ventricular diastolic function and structure independent of blood pressure and fasting plasma glucose level.

Abdominal wall hematoma related to severe cough in a patient under antiaggregant and anticoagulant therapy

A 56-year-old woman with coronary artery disease presented with the complaint of chest pain. She was hospitalized with the diagnosis of acute coronary syndrome. She was taking acetylsalicylic acid, metoprolol, atorvastatin and isosorbide mononitrate for coronary artery disease. The medical history included: diabetes mellitus, hypertension, and coronary artery bypass grafting surgery. The blood pressure was 170/100 mmHg and the heart rate was 94 beats/min. There was no significant finding on physical examination other than a mild systolic murmur at the apical region. Laboratory testing revealed the following values: glucose: 87 mg/dL, troponin I: 3.07 ng/mL, CK-MB: 18.3 U/L, hemoglobin: 8.6 g/dL, thrombocyte: 247,000/ mm and INR: 1.07. Besides the existing treatment, nitroglycerine infusion, subcutaneous enoxoparine, clopidogrel, amlodipine and perindopril medication was started. On the third day of treatment, a non-productive severe cough started. It was thought to be related with the ACE inhibitor, or an upper respiratory tract infection. The ACE inhibitor medication was converted to an angiotensin receptor blocker. On the fourth day of hospitalization, severe abdominal pain and a painful right upper quadrant mass developed (Fig. 1). The hemoglobin level decreased to 8.1 g/dL. Two units of red blood cell suspension were transfused. Abdominal ultrasound examination revealed an abdominal hematoma. All of the anticoagulant and antiaggregant medications were stopped. Abdominal computed tomography was performed. A 13.4 9 8.9 cm hematoma between the right internal oblique and external oblique muscles was detected (Fig. 2). Initially, the surgeons planed an operation to ligate the bleeding vessel under general anesthesia, but, because of the high risk of the patient due to the acute coronary syndrome, they suggested conservative non-operative management. Because of the patient’s unbearable pain, percutaneous catheter placement and drainage had to be performed. Control USG revealed reduced diameters of the hematoma. The cough improved 5 days after the conversion to an angiotensin receptor blocker; this suggested that the cause of the cough was the ACE inhibitor rather than upper respiratory tract infection. The patient recovered and was discharged. Cough is a vital reflex to clear airways for pulmonary clearing. Abdominal muscles suddenly contract to increase

In reference to Snoring and carotid artery intima-media thickness.

We read with great interest the recent article by Deeb et al. regarding the relationship that exists between snoring and intima-media thickness (IMT) of the carotid arteries. The authors very clearly discussed the relationship between primary snoring and IMT of the carotid arteries. They concluded that the relationship between increased carotid IMT and serious health conditions, and nonapneic snoring may be a precursor to changes of the carotid artery. In addition to their fluent discussion, we aim to emphasize the possible other effective mechanism of snoring and carotid artery IMT: the contribution of autonomic nervous system function. Previous studies clearly showed that obstructive sleep apnea syndrome (OSAS) and snoring lead to nocturnal intermittent hypoxia, increased negative intrathoracic pressure, increased sympathetic nervous system activity, and elevation of reactive oxygen radicals. All of these factors cause vascular atherosclerosis. Previously, we showed that a close relationship between OSAS and impaired autonomic nervous system function is detected by different methods in OSAS patients without coronary artery diseases or other comorbidities. Together with this, nocturnal intermittent hypoxiarelated impairment in autonomic nervous system function is thought to play a central role in the risk of cardiovascular death. Several studies in the literature showed that IMT of the carotid artery and impaired cardiac autonomic function are inversely related. Galetta et al. clearly illustrated the relationship between the imbalance of cardiac autonomic activity and the development of carotid artery IMT. They discussed that the imbalance of cardiac autonomic activity plays an important role in the development of atherosclerosis through three possible mechanisms: increased heart rate with a consequent increase in oxygen consumption, increased shear stress leading to plaque fissure, and enhanced atherosclerosis through increased macrophage low-density lipoprotein cholesterol oxidation. We believe that the effect of snoring and IMT on autonomic nervous system function may play a role in the results described in article by Deeb et al. We hope that the above-mentioned items will add to the value of their well-written article regarding the relationship that exists between snoring and IMT of the carotid arteries.