Aslı Tanındı

Red cell distribution width in patients with prehypertension and hypertension

Abstract Objective. Red cell distribution width (RDW) which is reported as part of complete blood count in routine clinical practice, is a measure of variability in size of the erythrocytes in the circulation. It is a novel predictor of mortality both in unselected populations and in some selected group of patients. We aimed to search whether RDW values differ between the healthy population and the patients with pre-hypertension and hypertension who are otherwise healthy, considering the widely accepted role of RDW as a prognostic marker especially for mortality. Patients and methods. Patients who were diagnosed with prehypertension or hypertension for the first time according to the Joint National Committee (JNC) 7 criteria and otherwise healthy were enrolled to the study. One-hundred and twenty-eight patients with hypertension, 74 patients with prehypertension and 36 healthy controls participated in the study. Complete blood count, biochemistry and erythrocyte sedimentation rates were measured by standard methods. Hemoglobin, white blood cell count, mean corpuscular volume, platelet count and RDW were recorded. Results. After adjustment for age, hemoglobin level, presence of anemia, serum uric acid level, erythrocyte sedimentation rate and mean corpuscular volume, mean RDW values were 15.26 ± 0.82, 16.54 ± 0.91 and 13.87 ± 0.94 in prehypertensive, hypertensive and control groups, respectively (p < 0.05). Systolic and diastolic blood pressures were strongly correlated with RDW (r = 0.848 and r = 0.748, respectively; p < 0.01). Conclusion. RDW is higher in prehypertensive and hypertensive patients compared with healthy controls independently of age, inflammatory status and anemia. Higher RDW values are strongly correlated with higher systolic and diastolic blood pressures.

Neutrophil to lymphocyte ratio is associated with more extensive, severe and complex coronary artery disease and impaired myocardial perfusion

OBJECTIVES We investigated the relation between neutrophil to lymphocyte ratio (N/L) and the extent, severity, and complexity of coronary artery disease (CAD) and myocardial perfusion. STUDY DESIGN One hundred and fifty-one patients who underwent coronary angiography with stable angina pectoris (SAP) (n=93) or acute coronary syndrome (ACS) (n=58) were included in the study. Blood samples were drawn before coronary angiography. Gensini and SYNTAX scores and myocardial blush grade (MBG) were assessed. RESULTS Neutrophil counts were 4.4±1.4 and 5.0±1.6 in the SAP and ACS groups (p=0.018), whereas lymphocyte counts were 2.2±0.7 and 2.1±0.7, respectively (p=0.104). N/L was 2.2±1.2 in the SAP and 2.6±1.0 in the ACS (p=0.002) groups. In patients with SAP, N/L was significantly correlated with Gensini and SYNTAX scores (Gensini score r=0.32, p=0.002; SYNTAX score r=0.36, p=0.000), but there was no significant correlation between N/L and MBG. In the ACS group, N/L had a more powerful association with both Gensini and SYNTAX scores (Gensini r=0.42, p=0.001; SYNTAX r=0.51, p=0.000). N/L was negatively correlated with MBG in ACS patients (r= -0.48, p=0.000). Significant correlations persisted both in the SAP and ACS groups after correcting for age, diabetes, hyperlipidemia, and statin use; however, the associations were weaker. Cut-off N/L to predict moderate to severe CAD according to SYNTAX score was 2.26, with 72% sensitivity and 71% specificity (area under the curve [AUC]: 0.772, 95% confidence interval [CI] 0.679-0.865, p<0.001). CONCLUSION N/L is associated with severe, extensive and complex CAD and may be used to predict moderate to severe involvement in patients with CAD.

Arterial stiffness and central arterial wave reflection are associated with serum uric acid, total bilirubin, and neutrophil-to-lymphocyte ratio in patients with coronary artery disease.

Objective Total bilirubin (TB) was recently recognized as an endogenous anti-inflammatory and anti-oxidant molecule. Uric acid (UA) takes part in cardiovascular diseases by inducing oxidative stress, inflammation, and endothelial dysfunction. We assessed the relationship between serum TB levels, serum UA levels, and inflammatory status assessed by neutrophil-to-lymphocyte ratio (N/L) and arterial stiffness and arterial wave reflection in patients with a clinical diagnosis of coronary artery disease (CAD). Methods We included 145 consecutive patients admitted with stable angina pectoris (SAP) or acute coronary syndrome (ACS). Blood samples were drawn at admission for complete blood count and biochemistry. Non-invasive pulse waveform analysis for the determination of augmentation index (AIx) and carotid-femoral pulse wave velocity (PWV) measurements were performed with the commercially available SphygmoCor system. Results When patients were divided into tertiles of PWV and AIx, median N/L and median serum UA levels were the highest and mean TB levels were the lowest in the third tertile (p<0.001 for all). AIx and PWV were positively associated with serum UA and N/L and negatively associated with serum TB levels (p<0.001 for all). After adjustments for age, gender, heart rate, systolic blood pressure, and presence of diabetes, significant correlations persisted for N/L, UA, and TB in ACS patients (p<0.05). In the SAP group, TB was significantly negatively correlated with AIx and PWV, and UA was significantly positively correlated with PWV (p<0.05). Conclusion N/L ratio and serum UA and TB levels might be used to risk-stratify patients with respect to arterial stiffness in CAD patients, especially in the presence of ACS.

Central pulse pressure amplification is associated with more extensive and severe coronary artery disease.

Abstract Objectives. We investigate the association between noninvasively determined central pulse waveform characteristics and the extent and severity of coronary artery disease (CAD) in patients undergoing coronary angiography with the clinical diagnosis of CAD. Design. We included 145 consecutive patients with stable angina pectoris (SAP), unstable angina pectoris (USAP), or acute myocardial infarction (AMI) who were decided to undergo coronary angiography. Gensini and SYNTAX scores were calculated. Noninvasive PWA was performed with the SphygmoCor system. Results. Dividing the patients into tertiles according to augmentation index (AIx), more patients had significant CAD with higher Gensini and SYNTAX scores and lower myocardial blush grade (MBG) (p < 0.001 for all) in the third tertile. The AIx value to predict the presence of moderate to severe CAD as determined by SYNTAX score ≥ 23 was 24.45% (ROC analysis AUC: 0.96; sensitivity 88%, specificity: 93%, 95% CI: 0.93–0.99, p < 0.001). AIx was significantly correlated with Gensini and SYNTAX scores in SAP, USAP, and AMI patients after adjusting for age, gender, height, heart rate, hypertension, and diabetes. Conclusions. Increased AIx is associated with the presence and severity of CAD, and it may be used in selected patients during cardiovascular evaluation in outpatient settings for risk stratification prior to coronary angiography.

Heart rate variability in patients hospitalized for decompensated diastolic heart failure at admission and after clinical stabilization.

AIMS We investigated heart rate variability (HRV) in patients hospitalized for decompensated diastolic heart failure and the effect of compensation course on HRV parameters. We also examined the association between the degree of diastolic dysfunction and HRV indices. PATIENTS & METHODS A total of 42 patients hospitalized for decompensated heart failure, who had a measured ejection fraction ≥ 50%, and ten age- and sex-matched healthy volunteers were enrolled. RESULTS All HRV indices were lower compared with the control group both at admission (p < 0.001) and after compensation, although a significant increase was observed in each index measured after clinical stabilization (p < 0.001). Improvement in HRV indices was lowest in patients with a restrictive pattern among groups of different degrees of diastolic dysfunction. CONCLUSION Impairment in HRV in decompensated diastolic heart failure is more pronounced with increasing grade of diastolic dysfunction. It remains to be investigated whether decompensation may be predicted by marked depression in these indexes or if severely impaired HRV is a consequence of decompensation.

Guideline-adherent therapy for stroke prevention in atrial fibrillation in different health care settings: Results from RAMSES study

OBJECTIVE No studies have been conducted in Turkey to compare the quality of stroke prevention therapies provided in different healthcare settings in patients with atrial fibrillation (AF). Therefore, we aimed to evaluate possible differences between secondary (SH) and tertiary hospital (TH) settings in the effectiveness of implementing AF treatment strategies. METHODS Baseline characteristics of 6273 patients with non-valvular AF enrolled in the RAMSES (ReAl-life Multicentre Survey Evaluating Stroke Prevention Strategies in Turkey) study were compared. RESULTS Of the study population, 3312 (52.8%) patients were treated in THs and 2961 (47.2%) patients were treated in SHs. Patients treated in the SH setting were older (70.8±9.8 vs. 68.7±11.4years, p<0.001), had a lower socioeconomic status, had a higher CHA2DS2VASc and HASBLED scores (3.4±1.4 vs. 3.1±1.7, p<0.001 and 1.7±1.0 vs. 1.6±1.1, p<0.001 respectively), and had more comorbidities than patients treated in THs. Inappropriate oral anticoagulant use was more prevalent in SHs than THs (31.4% vs. 25.6%, p<0.001). When over- and undertreatment rates were compared among hospital types, overtreatment was more prevalent in THs (7.6% vs. 0.9%, p<0.001) while undertreatment was more common in SHs (30.5% vs. 17.9%, p<0.001). CONCLUSION This study demonstrates the marked disparity between patient groups with AF presenting at SHs and THs. The use of guideline-recommended therapy is not adequate in either type of centre, overtreatment was more prevalent in THs and undertreatment was more prevalent in SHs.

Tp-e/QT ratio and QT dispersion with respect to blood pressure dipping pattern in prehypertension.

IntroductionTp-e/QT, the ratio of the interval between the peak and the end of T wave to the QT interval, is a novel index of arrhythmogenesis. We investigate Tp-e/QT and QT dispersion (QTd) in prehypertensive and normotensive patients with different patterns of nocturnal blood pressure dipping. Patients and methodsForty-seven prehypertensive and 37 normotensive adult patients were included. Ambulatory blood pressure monitoring recording was performed and patients were considered to be dipper if nocturnal blood pressure fall was at least 10%; nondipper if it was 0–10%; and reverse-dipper if less than 0%. Tp-e, QT intervals were assessed by 12-lead ECG and Tp-e/QT was calculated using these measurements. QTd is defined as the difference between the maximum and the minimum QT interval of the 12 leads. ResultsTp-e/QT was 0.22±0.02 and 0.16±0.01 in prehypertensives and normotensives, respectively (P<0.001), whereas cQTd was 36.1±6.8 and 27.2±5.2 ms (P<0.001). Tp-e and Tp-e/QT were the lowest in the dippers and the highest in the reverse-dippers in the prehypertensive group (Tp-e/QT dipper: 0.21±0.01; nondipper: 0.24±0.02; reverse-dipper: 0.25±0.01; for dipper–nondipper, and dipper–reverse-dipper P<0.05). However, in the normotensive group, dipping status had no effect on Tp-e/QT. There were no significant differences between dippers, nondippers, and reverse-dippers in terms of cQTd both in prehypertensives and in normotensives. There were no associations between left ventricular mass index and Tp-e, Tp-e/QT, and cQTd in both groups. ConclusionTp-e, Tp-e/QT, and cQTd are increased in prehypertensives compared with normotensives. Tp-e and Tp-e/QT are associated with the dipping status in prehypertensives.

exercise electrocardiographic responses and serum cystatin c levels among metabolic syndrome patients without overt diabetes mellitus

Objectives: An impaired heart rate response during exercise (chronotropic incompetence) and an impaired heart rate recovery (HRR) after exercise are predictors of cardiovascular risk and mortality. Cystatin C is a novel marker for cardiovascular disease. We aimed to investigate exercise electrocardiographic responses in patients with metabolic syndrome who were without overt diabetes mellitus, in addition to the association of serum cystatin C levels with the exercise electrocardiographic test results. Method: Forty-three consecutive patients admitted to a cardiology outpatient clinic without angina pectoris were recruited if they met criteria for metabolic syndrome but did not have overt diabetes mellitus. Serum cystatin C levels were measured, and all participants underwent exercise electrocardiographic testing. Patients who were found to have ischemia had a coronary angiography procedure. Results: The mean cystatin C level of patients was higher in metabolic syndrome group than healthy controls (610.1 ± 334.02 vs 337.3 ± 111.01 μg/L; P < 0.001). The percentage of patients with ischemia confirmed by coronary angiography was 13.9% in the metabolic syndrome group. Cystatin C levels in the ischemic patients of the metabolic syndrome group were higher than that in nonischemic patients (957.00 ± 375.6 vs 553.8 ± 295.3 μg/L; P = 0.005). Chronotropic incompetence was observed in 30.2% of the patients with metabolic syndrome compared with 16.7% in the control group (P = 0.186). Chronotropic response indices were 0.8 ± 0.18 versus 0.9 ± 0.10 for the two groups, respectively (P = 0.259). HRR was significantly lower in the metabolic syndrome patients compared with the controls (20.1 ± 8.01 vs 25.2 ± 4.5 per min; P < 0.001), and the ST-segment adjustment relative to heart rate(ST/HR index ratio) was 1.4 ± 1.34 versus 0.4 ± 0.31 μV/beat (P < 0.001), respectively. Cystatin C was negatively correlated with the chronotropic response index (CRI) and HRR and was positively correlated with ST/HR index in the entire study population (R = −0.658, −0.346, 0.388, respectively; P < 0.05). Conclusions: A substantial proportion of metabolic syndrome patients without overt diabetes mellitus had silent coronary ischemia in addition to impairment of objective exercise electrocardiographic parameters. In the metabolic syndrome patients without overt diabetes mellitus, cystatin C levels were found to be elevated and the elevation was more pronounced in the subgroup with silent ischemia. Cystatin C was also correlated with HRR and CRI.

Impact of Admission Blood Glucose on Coronary Collateral Flow in Patients with ST-Elevation Myocardial Infarction

In patients with acute myocardial infarction, glucose metabolism is altered and acute hyperglycemia on admission is common regardless of diabetes status. The development of coronary collateral is heterogeneous among individuals with coronary artery disease. In this study, we aimed to investigate whether glucose value on admission is associated with collateral flow in ST-elevation myocardial infarction (STEMI) patients. We retrospectively evaluated 190 consecutive patients with a diagnosis of first STEMI within 12 hours of onset of chest pain. Coronary collateral development was graded according to Rentrop classification. Rentrop 0-1 was graded as poor collateral development, and Rentrop 2-3 was graded as good collateral development. Admission glucose was measured and compared between two groups. Mean admission glucose level was 173.0 ± 80.1 mg/dl in study population. Forty-five (23.7%) patients had good collateral development, and 145 (76.3%) patients had poor collateral development. There were no statistically significant differences in demographic characteristics between two groups. Three-vessel disease was more common in patients with good collateral development (p=0.026). Mean admission glucose level was higher in patients with poor collateral than good collateral (180.6 ± 84.9 mg/dl versus 148.7 ± 56.6 mg/dl, resp., p=0.008). In univariate analysis, higher admission glucose was associated with poor collateral development, but multivariate logistic regression analysis revealed a borderline result (odds ratio 0.994, 95% CI 0.989–1.000, p=0.049). Our results suggest that elevated glucose on admission may have a role in the attenuation of coronary collateral blood flow in acute myocardial infarction. Further studies are needed to validate our results.

Blood pressure morning surge, exercise blood pressure response and autonomic nervous system

Abstract Objective. We investigated blood pressure (BP) response to exercise with respect to BP morning surge (MS), and the association between MS, exercise treadmill test (ETT) and heart rate variability (HRV) indices. Design. Eighty-four healthy subjects without hypertension were enrolled. Ambulatory BP monitoring and 24-hour Holter recordings were obtained for sleep-trough MS and HRV indices: low-frequency (LF) component, high-frequency (HF) component and LF/HF ratio. ETT was performed, and BPs were obtained at rest, end of each stage, and recovery. Third-minute heart rate recovery (HRR) and BP recovery ratio (BPRR) were calculated. Results. When analysed in quartiles of MS, systolic BP at low workloads was higher in the highest than in the lowest quartile, although maximum BPs at maximum exercise were not significantly different. BPRR was highest in the highest quartile in contrast to HRR, which was lowest in the highest quartile. LF/HF was highest during both at daytime and night-time in the highest quartile. BPRR and LF/HF were positively, and HRR was inversely associated with MS. Conclusions. Subjects with a high MS have higher BP at low workloads, at which most daily activities are performed, and impairment in some indices, which indirectly reflect the autonomic nervous system.