Alper Kepez

Detection of Subclinical Cardiac Involvement in Systemic Sclerosis by Echocardiographic Strain Imaging

Background: Cardiac involvement is one of the major problems in systemic sclerosis (SSc). Subclinical cardiac involvement has a higher frequency than thought previously. In this study we investigated whether subclinical cardiac involvement can be detected by using echocardiographic strain imaging in SSc patients without pulmonary hypertension. Methods: Echocardiographic examinations were performed to 27 SSc patients and 26 healthy controls. Left ventricular strain parameters were obtained from apical views and average strain value was calculated from these measurements. Results: There were no significant differences between patients and controls regarding two‐dimensional (2D), conventional Doppler and tissue Doppler velocity measurements. Strain was reduced in 6 of 12 segments of the left ventricle (LV) and in 1 of 2 segments of the right ventricle (RV). Strain rate (SR) was reduced in 2 of 12 segments of the LV and 1 of 2 segments of the RV in SSc patients as compared to controls (P < 0.05 for all). These involvements did not match any particular coronary artery distribution. More important differences were detected by average strain and SR values of the LV between patients and controls (19.78 ± 3.00% vs 23.41 ± 2.73%, P < 0.001; 2.01 ± 0.41 vs 2.23 ± 0.27/sec, P = 0.026, respectively). Furthermore, carbon monoxide diffusion capacity (DLCO) in scleroderma patients significantly correlated with LV average strain (r = 0.59; P = 0.001). Conclusion: Evaluation of ventricular function by using echocardiographic strain imaging appears to be useful to detect subclinical cardiac involvement in SSc patients with normal standard echocardiographic and tissue Doppler velocity findings.

Peroxisome Proliferator-Activated Receptor-γ

Insulin resistance and obesity is a common health problem in the industrialized world. As a result of the availability of high-calorie food and a reduction in energy expenditure, maladaptive metabolic processes may interfere with the action of insulin and increase susceptibility for the development of atherosclerotic cardiovascular diseases. With the advent of peroxisome proliferator-activated receptors (PPARs), the mechanisms of this maladaptation and its relationship to insulin resistance syndrome components have become less obscure, promising new therapeutic approaches for this common problem. In this review we first focus on the molecular structure and cellular mechanisms of action of these receptors and then discuss how PPAR-γ, a PPAR isoform, provides a link between adiposity, insulin resistance, and atherosclerosis.

Early myocardial functional alterations in patients with obstructive sleep apnea syndrome.

Background: There is limited information regarding myocardial alterations in patients with obstructive sleep apnea syndrome (OSAS) in the absence of pulmonary and cardiac comorbidity. In this study, we aimed to evaluate potential myocardial alterations of these patients and investigate the possible effects of OSAS‐related pathological variations on left and right ventricular functions. Methods: We studied 107 consecutive patients who were referred to our sleep laboratory for clinically suspected OSAS and 30 controls without any history or symptoms of sleep‐related disorders. Severity of OSAS was quantified by polysomnography. Patients with apnea–hypopnea index (AHI) < 5 were included in the OSAS (−) group (Group 1, n = 22). Subjects with AHI ≥ 5 were considered as OSAS and classified according to their AHI as mild‐to‐moderate (AHI ≥ 5 and AHI < 30) (Group 2, n = 45) and severe (AHI ≥ 30) OSAS groups (Group 3, n = 40). Conventional M‐mode, 2D, and Doppler mitral inflow parameters, tissue Doppler velocities, myocardial peak systolic strain, and strain rate values of various segments were measured and compared between groups. Results: Patients with OSAS displayed impairment of left ventricular diastolic function compared with controls. There were no significant differences between groups regarding parameters reflecting left ventricular systolic function. Myocardial strain analysis demonstrated significant decrement regarding apical right ventricular longitudinal peak systolic strain and strain rate values between groups in relation to the severity of OSAS. Conclusions: Patients with OSAS display a regional pattern of right ventricular dysfunction correlated with the severity of disease.

Evaluation of association between obstructive sleep apnea and coronary risk scores predicted by tomographic coronary calcium scoring in asymptomatic patients.

OBJECTIVE This cross-sectional observational study is designed to evaluate direct effects of obstructive sleep apnea syndrome (OSA) on presence and extent of coronary atherosclerosis by using tomographic coronary calcification scoring on a population asymptomatic for coronary artery disease. METHODS Ninety-seven consecutive patients (49.17 ± 0.86 years) who were evaluated with sleep study for the suspicion of obstructive sleep apnea syndrome underwent tomographic coronary calcium scoring test. Cardiovascular risk factors, current medications and sleep study recordings of all patients were recorded. Patients were classified into 4 groups according to the apnea-hypopnea index (AHI). Linear and logistic regression analyses were used for assessment of association between variables. RESULTS Coronary risk scores of patients, assessed by tomographic coronary calcium scoring, were observed to increase linearly from simple snoring group to severe OSA groups (p=0.046). When patients were classified according to their gender, AHI and parameters reflecting severity of OSA-related hypoxia were found to correlate significantly with coronary risk scores of women but not with scores of men. Linear regression analysis revealed age as the only independent associated variable with cardiovascular risk scores assessed by tomographic coronary calcification scoring (Beta coefficient: 0.27, 95% CI 0.007-0.087, p=0.018). Binary logistic regression analysis also revealed age as the only variable which independently predicted the presence of coronary calcification (OR:1.11, 95% CI 1.039-1.188, p=0.002). CONCLUSION These results suggest that presence of OSA may contribute to coronary artery disease risk of patients in association with its severity; however, association between OSA and subclinical atherosclerosis seems to be primarily dependent on age.

The relationship between B-type natriuretic peptide levels and echocardiographic parameters in patients with heart failure admitted to the emergency department.

OBJECTIVE Brain natriuretic peptide (BNP) is a peptide, which has recently been used in the differential diagnosis and follow-up of patients with heart failure. Our aim in the present prospective and diagnostic designed study is to investigate the role of BNP in determining the etiology of dyspnea and to evaluate its relation with newer echocardiographic parameters. METHODS Thirty-four patients presenting to the emergency department with dyspnea and fulfilling the Framingham criteria for heart failure were included in the study. Blood samples were obtained in the first hour of presentation for measurement of BNP levels from all patients. Detailed transthoracic two-dimensional, Doppler and tissue Doppler echocardiographic studies were then performed within 24 hours of presentation. Statistical analyses were performed using Students t-test for independent samples, Mann Whitney U test and Pearson or Spearman correlation tests. RESULTS Plasma BNP levels were found to be significantly correlated with left ventricular end-systolic and end-diastolic diameter, left atrial diameter and the degree of mitral insufficiency (r=0.46, p=0.007; r=0.39, p=0.02; r=0.32, p=0.065; r=0.50, p=0.014, respectively). A significant inverse correlation was observed between plasma BNP levels and left ventricular ejection fraction (r=-0.5, p=0.003). When the patients were grouped according to their BNP levels, the mean ejection fraction of the group with BNP levels below median (578 pg/l) was 60.65+/-13.84%, whereas the mean ejection fraction of the group with BNP levels of 578 pg/l or above (BNP 2) was 49.41+/-15.26% (p=0.027). Out of parameters reflecting left ventricular diastolic functions, only transmitral Epeak/Apeak ratio was found to be significantly associated with BNP levels (r=0.4, p=0.05). Tissue Doppler study revealed significant correlations between BNP levels and right ventricular basal and midsystolic velocities (r=-0.507, p=0.008; r=-0.562, p=0.005, respectively) while none of the left ventricular tissue velocities displayed significant correlation with BNP values. CONCLUSION Plasma BNP levels are found to be significantly associated with conventional echocardiographic parameters reflecting left ventricular systolic and diastolic functions and tissue Doppler velocities reflecting right ventricular functions. Our findings are in agreement with the notion that plasma BNP levels are beneficial in the differential diagnosis of patients admitted to emergency service with acute dyspnea.

Prevalence of coronary artery disease before valvular surgery in patients with rheumatic valvular disease.

BackgroundAlthough many patients with valvular heart disease have concomitant coronary artery disease (CAD), there are limited data on the association between rheumatic valvular disease (RVD) and CAD. In this study, we aimed to investigate the prevalence of CAD in a group of patients with RVD and undergoing coronary angiography before valvular surgery. MethodsIn this retrospective analysis, we enrolled a total of 1075 patients (658 women, 61.2%; mean age: 53.2±9.9 years) who underwent coronary angiography for the evaluation of CAD before valvular surgery between January 2003 and May 2010. ResultsThe overall prevalence of significant CAD was 11.1%. Patients with significant CAD were older than patients without significant CAD (55.16±10.4 vs. 51.45±9.1; P<0.001). In addition, hypertension, smoking, diabetes mellitus, and dyslipidemia were more prevalent among patients with significant CAD (P<0.05). After adjustment for several risk factors, only aortic stenosis remained the predictor of significant CAD (odds ratio: 1.66; 95% confidence interval: 1.26–2.19; P<0.001). However, aortic regurgitation was inversely associated with the presence of CAD (odds ratio: 0.56; 95% confidence interval: 0.21–1.01; P<0.001). ConclusionThe overall prevalence of CAD in our population with RVD was low. Rheumatic aortic stenosis is associated with an increased prevalence of CAD, whereas the prevalence of CAD is lower in those patients with aortic regurgitation.

Serum Antioxidant Vitamin Levels in Patients with Coronary Heart Disease

The aim of this study was to investigate anthropometric measurements, body composition, and serum antioxidant vitamin levels in men with coronary heart disease (CHD). Thirty-five men with CHD and 31 men without CHD, aged 40 - 65 years, were included this study. Dietary records and anthropometric measurements of each participant were recorded by researchers and serum antioxidant vitamin levels and lipid profiles were analyzed. Fat mass (FM) and the percentage of fat mass (FM%) in men with CHD was higher than in men without CHD (p < 0.05). Lipid profiles were found to be similar in both groups, with the exception of high-density lipoprotein cholesterol (HDL-C). Men with CHD had lower HDL-C levels than men without CHD (p < 0.05). When the antioxidant vitamin intake of participants was investigated, vitamin E intake in men without CHD was found to be less than in men with CHD (p < 0.05). However, serum vitamin A, vitamin E, and vitamin C levels in men with CHD were found to be lower than in men without CHD (p < 0.05). Based on the results of this study, we propose that high FM, low HDL-C, and low serum antioxidant vitamin levels could be important risk factors for CHD.

Alterations of von Willebrand Factor and Ristocetin Cofactor Activity During Atrial Fibrillation

The aim of this study was to assess the plasma levels of von Willebrand factor antigen and ristocetin cofactor activity, which are well-known markers of endothelial function, in atrial fibrillation (AF) with or without mitral stenosis (MS). Forty-two patients (16 patients with MS and AF [MS(+)AF(+)], 13 patients with nonvalvular AF [MS(−)AF(+)], and 13 patients with MS and sinus rhythm [MS(+)AF(−)]) were included. Von Willebrand factor antigen levels and ristocetin cofactor activities in all participants were assessed. Overall, von Willebrand factor antigen levels and ristocetin cofactor activities in the AF(+) patients were higher than in the AF(−) patients (P = .003 and P = .002, respectively). Von Willebrand factor antigen levels and ristocetin cofactor activities in the 3 groups were found to be different (P = .012 and P = .01, respectively). Von Willebrand factor antigen levels were similar between the MS(+)AF(+) and MS(−)AF(+) groups and were higher than that of the MS(+)AF(−) group. Ristocetin cofactor activity in the MS(−)AF(+) group was significantly higher than in the other 2 groups. The ristocetin cofactor activity and von Willebrand factor antigen levels were significantly higher in diabetic or hypertensive patients than in nondiabetic or normotensive patients. According to the results of this study, circulating von Willebrand factor antigen levels and plasma ristocetin cofactor activities are affected by the presence of AF, MS, and associated comorbidities including type 2 diabetes mellitus and systemic hypertension. Further studies are needed to assess the role of von Willebrand factor antigen and ristocetin cofactor activity in predicting vascular thrombotic events in AF, MS, systemic hypertension, and diabetes mellitus.

The anatomical relationship between the axillary artery and vein investigated by radial coronary angiography: SERT et al.

To reduce the risk of inadvertent arterial puncture and bleeding, we aimed to define a safe puncture site by demonstrating the relation of the axillary artery and vein.

Arrhythmogenic epilepsy and pacing need: A matter of controversy.

There is increasing awareness among the cardiology community regarding ictal bradyarrhythmias as a cause of loss of consciousness. A high degree of suspicion is necessary when diagnosing ictal bradyarrhythmias, and delay in diagnosing this condition may lead to morbidity associated with falls and trauma. Ictal bradyarrhythmias have also been suggested to be associated with sudden unexplained death in epilepsy, although evidence related to this association is limited. There is no guideline-directed therapy for symptomatic ictal bradyarrhythmias due to a lack of randomized, controlled trials. Cardiac pacemaker therapy is commonly used for these patients; however, currently, there is no universal agreement on the pacing indications for these patients. In this review, we focus on the pathophysiology and clinical presentation of ictal bradyarrhythmias and then discuss the pacing need based on the available literature data.