Asli Atar

Adenosine‐Induced Ventricular Arrhythmias in Patients with Supraventricular Tachycardias

Background: Adenosine is widely used for the diagnosis and the termination of supraventricular arrhythmias. There are many case reports and few series about the proarrhythmic potential of adenosine. We sought to evaluate the proarrhythmic potential of adenosine used to terminate the supraventricular arrhythmias.

Effects of rosiglitazone on plasma brain natriuretic peptide levels and myocardial performance index in patients with type 2 diabetes mellitus.

Thiazolidinediones (TZD) have become a powerful tool for lowering insulin resistance. The problem of cardiovascular adverse events including fluid retention and risk of heart failure should be well known and recognised. We aimed to evaluate the long-term effects of rosiglitazone on cardiac function and fluid dynamics. Forty-six type 2 diabetic patients were randomised to treatment with rosiglitazone or metformin or to a control group. There are no significant differences between the groups in the duration of diabetes, HbA1c, plasma brain natriuretic peptide (BNP) levels, body mass index and myocardial performance indexes (MPIs) before the treatment. After three and six months all these parameters were repeated. Rosiglitazone increased plasma BNP levels and worsened MPIs 3 months after the start of treatment. Also left ventricular end-systolic volume increased and weight gain was observed. But these results were statistically non-significant (all p>0.05). When we continued rosiglitazone treatment to six months the increase in BNP levels became soft and statistically significant improvements were seen in MPIs (p<0.01). Also left ventricular end-systolic volume decreased significantly (p=0.004) and weight gain was stopped. In patients with type 2 diabetes, TZD treatment might have slight adverse effects on ventricular contractility and fluid dynamics at the beginning of the therapy. However, these changes seem to stabilise in the long term.

Serum uric acid level is an independent risk factor for presence of calcium in coronary arteries: an observational case-controlled study.

OBJECTIVE A link between uric acid levels and cardiovascular diseases has been previously reported. Coronary artery calcium score (CACS) is a marker of atherosclerotic disease and a predictor of cardiovascular events. We sought to determine if serum uric acid level is an independent risk factor for the presence of calcium in coronary arteries. METHODS Four hundred and forty-two patients who were evaluated in the cardiology outpatient clinic for suspected coronary heart disease with a low-moderate risk for coronary artery disease were included in this observational case-controlled study. Serum uric acid levels were measured with colorimetric methods. CACS were performed using a 64-slice CT scanner. Patients were divided to 3 groups according to their CACS value (Group 1: CACS=0, Group 2: CACS 1-100, Group 3: CACS>100). RESULTS The demographical characteristics and laboratory findings of 3 groups were similar, except age, fasting glucose levels and serum uric acid levels. Serum uric acid levels were found to increase significantly with increasing CACS (p=0.001). Patients were grouped according to presence CAC (CACS=0 and CACS≥1) and in the multiple regression analysis, age (OR, 1.11, 95% CI, 1.07-1.16), smoking (OR, 3.83, 95% CI, 2.06-7.09), serum uric acid levels (OR, 1.26, 95% CI, 1.04-1.54) and average 10-year total risk of Framingham risk score (OR, 1.13, 95% CI, 1.04-1.09) appeared as independent factors predictive of presence of CAC (p<0.05). CONCLUSION Serum uric acid level is an independent risk factor for presence of coronary calcium. Moreover, increasing levels of serum uric acid are associated with increasing CACS.

The Clinical Significance of Aspirin Resistance in Patients With Chest Pain

There are conflicting data in the literature about the clinical significance of aspirin resistance.

Two cases of coronary vasospasm induced by 5-fluorouracil.

The first case is a 40-year-old female patient with adenocarcinoma of the cecum who was started on continuous intravenous (i.v.) 5-FU (425 mg/m2/day) and folinic acid (25 mg/m2/day) infusion. The patient had no history of heart disease. On the third day of 1st cycle, she developed chest pain. The electrocardiogram (ECG) showed ST segment elevation in leads II, III, aVF, V5 and V6 (Fig. 1a). The angina and ECG changes disappeared after sublingual nitrate administration (Fig. 1b). She continued to experience angina despite discontinuation of 5-FU, so she was admitted to the coronary care unit (CCU). She was heparinized with a 5000 U i.v. bolus followed by 1000 U/hr infusion and was started on a 5 mg/min nitroglycerine infusion, with the rate gradually increased to 100 mg/min. She continued to have anginal attacks of decreasing frequency and severity till day 4 of the i.v. heparin and nitrate therapy. Her serum levels of creatine kinase (CPK) and CPK-MB, and troponin-I remained within normal limits. Echocardiography was normal at all times. A coronary angiography was performed. The coronary arteries were normal (Fig. 2a). The fractional flow reserve (FFR, defined as the ratio of the mean pressure distal to a coronary stenosis to the mean aortic pressure during maximal hyperemia, indicates significant stenosis if <0.75) was measured to rule out any significant stenosis. FFR of the left anterior descending (LAD) and circumflex (Cx) arteries were measured. The FFR for the LAD artery was 1.02 (102/100), and this remained unchanged after an intracoronary injection of adenosine. The FFR of the Cx artery was 1.01 (102/101). Hyperventilation-induced respiratory alkalosis did not cause vasospasm in the coronary arteries. However, the cold pressor test, performed by placing the patient’s left arm in ice-cold water, resulted in 30-40% narrowing of the Cx artery (Fig. 2b). The patient’s chemotherapy regime was changed. She was discharged on oral diltiazem 90 mg/day. She remained free of any cardiac symptoms in follow-up. Our second case is a 63-year-old man who had coronary artery disease. He had adenocarcinoma of the duodenum and was started i.v. 5-FU (425 mg/m2/day) and folinic acid (25 mg/m2/day). On the 3rd day of the regimen shortly after the continuous infusion of 5-FU, the patient developed chest pain with ST segment elevation in leads II, III, aVF, V4, V5 and V6 (Fig. 3A). He was admitted to CCU and i.v. nitroglycerine and diltiazem infusion was started. The ST segment changes (Fig. 3B) and Two cases of coronary vasospasm induced by 5-fluorouracil

The effects of prior calcium channel blocker therapy on creatine kinase-MB levels after percutaneous coronary interventions.

Background: Use of intracoronary calcium channel blockers (CCBs) during percutaneous coronary intervention (PCI) has been shown to have favorable effects on coronary blood flow. We aimed to investigate the effects of CCBs administrated perorally on creatine kinase-MB (CK-MB) levels in patients undergoing elective PCI. Methods: A total of 570 patients who underwent PCI were evaluated for CK-MB elevation. Patients who were on CCB therapy when admitted to the hospital constituted the CCB group. No CCBs were given to the rest of the patients during the periprocedural period and these patients served as the control group. Blood samples for CK-MB were obtained before and at 6 h, 24 h, and 36 h after the procedure. Results: 217 patients were in the CCB group (mean age 60.2 ± 9.3 years, 162 males), and 353 were in the control group (mean age 60.0 ± 10.1 years, 262 males). CK-MB levels increased above the normal values in 41 patients (18.9%) of the CCBs group and in 97 patients (27.5%) of the control group (p = 0.02). Median CK-MB levels were significantly higher in the control group for all studied hours (for all p < 0.05). Conclusions: Prior oral CCB therapy may have favorable effects in preventing myocyte necrosis after elective PCI.

Evaluation of Right Ventricular Diastolic Function in Patients with Chronic Obstructive Pulmonary Disease Using Pulsed Doppler Tissue Imaging

Objective: To evaluate the global and segmental diastolic function of the right ventricle using pulsed tissue Doppler imaging (TDI) in patients with clinically stable chronic obstructive pulmonary disease (COPD) without pulmonary hypertension (PHT). Methods: Twenty stable patients with COPD (mean age 61.4±8.6, 16 males) with normal pulmonary artery pressure (PAP) (Group I) and 20 age-matched normal subjects (mean age Original Research Article Ugurlu et al.; JAMPS, 2(3): 107-116, 2015; Article no.JAMPS.2015.014 108 57.8±4.0, 11 males, Group II) were enrolled. All the participants underwent conventional echocardiography and TDI. TDI of the right ventricle was performed from four different segments. The early myocardial diastolic peak velocity (Em), late myocardial diastolic peak velocity (Am), systolic peak velocity (Sm), early diastolic velocity deceleration time (eDTm), duration of the S wave, isovolumetric relaxation time (IVRTm), and isovolumetric contraction time (IVCTm) were measured. Results: The conventional echocardiographic measurements of the two groups were similar, but specific TDI parameters differed between the groups. The Em of the anterior wall was lower, and the duration of the anterior S wave and IVRTm in the apical 4-chamber (A4C) view for all the right ventricular (RV) segments were longer. The eDTm measured from the apex was shorter in the COPD patients (parasternal Em, p=0.003; duration of anterior wall S wave, p=0.02; A4C apical IVRTm, p=0.02; A4C middle IVRTm, p=0.001; A4C basal IVRTm, p=0.01; A4C apical eDTm, p=0.05). Conclusion: TDI was more sensitive than conventional echocardiography in the evaluation of diastolic function in the patients with COPD. In COPD patients with an unlikely diagnosis of PHT, the diastolic functions of the right ventricle seemed to show some deterioration, but this difference failed to reach a significant level. Measurements of the basal segment of the RV free wall can be used to determine global RV diastolic function.

Two cases of acute coronary syndrome after intake of Clavis PANAX, coincidence or consequence?

Atherosclerotic cardiovascular disease is an epidemic in todays world. It is one of the most common causes of hospitalization and death. Therefore, remedies to control or heal the disease are continuously sought. In addition to scientifically researched therapies, patients frequently utilize alternative medicine. However, effective and toxic doses, metabolisms, and drug interactions of the herbs and herbal nutrition supplements are largely unknown. Herein, we present two cases with acute coronary syndrome. The first case was admitted with a diagnosis of acute inferior myocardial infaction (MI) and a stent was implanted to the occluded right coronary artery (RCA). There was a 50% stenosis in his left anterior descending artery (LAD). He was admitted with a diagnosis of non-ST elevation MI (NSTEMI) 6 months later. In the coronary angiogram, there was stent restenosis in RCA, the lesion in LAD had become thrombotic and progressed to a stenosis of 90%. He was referred to surgical revascularization. The second case was admitted for acute inferior MI and a stent was implanted to the occluded circumflex artery. Two months later, he was hospitalized for NSTEMI. Progression of coronary plaques to stenosis and stent restenosis was detected and he was referred to surgical revascularization. Both patients used the product sold as Clavis Panax, which contains panax ginseng, tribulus terrestris, and oat, after their first coronary intervention. Intake of a mixture of plant extracts may have serious consequences in humans as drug interactions and side effects are unknown.