Ayhan Usal

Effects of Trimetazidine on Heart Rate Variability and Left Ventricular Systolic Performance in Patients with Coronary Artery Disease After Percutaneous Transluminal Angioplasty

Fifty-one patients (mean age 51.6 ± 7.1 years) with angiographically proven coronary artery disease (CAD) entered the study. In 26 patients (Group I), trimetazidine treatment started twenty-four hours after percutaneous transluminal coronary angioplasty (PTCA). Another 25 patients (Group II) without trimetazidine treatment were kept as controls. The groups were comparable by age, gender, risk factors of CAD, coronary anatomy, left ventricular performance, and heart rate variability indices at baseline state. Power spectral analysis of heart rate variability and two-dimensional and Doppler echocardiographic examinations were performed before PTCA, and twenty-four hours, ten days, thirty days, and three months after PTCA. A statistically significant improvement of left ventricular systolic performance (P<0.001), augmentation of the parasympathetic band of heart rate variability (P<0.001), and decline of P1/P2 ratio (P<0.01) were evident in patients treated with trimetazidine, while no apparent changes were observed in controls. The intergroup analysis also showed marked difference between groups as recorded on the day 30 and month 3 of observation (P<0.001). During follow-up period recurrences of angina pectoris and ischemia were registered in Group II, while no evidence of ischemia was discerned in Group I patients. In conclusion, trimetazidine modulates the autonomic control of heart rate, ie, reduces sympathetic overactivity and augments vagal influences, improves left ventricular contractility, and diminishes the clinical manifestations of ischemia in patients with CAD after PTCA.

Renal vascular resistance in progressive systemic sclerosis: evaluation with duplex Doppler ultrasound.

The study was planned to evaluate renal vascular resistance by means of duplex Doppler ultra sonography in patients with progressive systemic sclerosis (PSS) with or without signs of renal involvement. Twenty-two female patients with PSS (mean age 38.5 ± 17.3 years) and 20 age-matched (mean age 36.7 ±7.2 years) female healthy controls participated to the study. Doppler indices of renal vascular resistance—resistive index (RI), pulsative index (PI), and systolic-to-diastolic flow velocities ratio (S/D ratio)—were determined on main renal artery and interlobar artery. RI, PI and S/D ratio were found to be increased in PSS patients with signs of renal involvement as compared to those without renal manifestations and healthy controls (p<0.0001 for all groups). Doppler indices of renal vascular resistance were closely related to the duration of the disease, age, and plasma renin activity. Doppler ultrasound is a useful and informative technique in the monitoring of PSS patients with renal involvement.

The effect of early statin treatment on inflammation and cardiac events in acute coronary syndrome patients with low-density lipoprotein cholesterol.

We investigated the effects of atorvastatin on inflammation and cardiac events during the inpatient period and initial 6-month follow-up in acute coronary syndrome (ACS) patients with low low-density lipoprotein (LDL) cholesterol level. One hundred and twelve consecutive ACS patients with LDL cholesterol less than 100 mg/dl were included in the study (mean 78.2 ± 12.3 mg/dl). While 70 randomly selected patients received a dose of 40 mg atorvastatin within the first 24 h on top of their standard treatment as the atorvastatin group, the remaining 42 patients considered as the control group were given the standard treatment only, i.e., without any lipid-lowering drug therapy. Lipid profile, high-sensitivity C-reactive protein (hsCRP), and plasma amyloid A (SAA) levels were measured in all patients within the first 24 h of chest pain, on the 5th day, and in the 6th month. During the inpatient period and subsequent 6-month follow-up, all episodes of angina, reinfarction, revascularization, heart failure, rehospitalization, cardiac mortality, and total number of cardiac events were recorded. In the atorvastatin group, hsCRP and SAA values on the 5th day and in the 6th month compared to the first 24 h were significantly lower than those of the control group (P < 0.0001). Mean LDL cholesterol level was significantly decreased in the atorvastatin group (55.7 ± 17.7 mg/dl), but there was no significant change in the control group at the 6th month. The frequency of heart failure during the inpatient period and angina, unstable angina pectoris, heart failure, and revascularization in the first 6 months were also significantly reduced in the atorvastatin group. Atorvastatin started in the first 24 h reduces inflammation and improves the prognosis during both the inpatient period and the first 6 months of clinical follow-up in ACS patients with low LDL cholesterol levels.

Cardiac troponin T as a prognostic marker in patients with heart failure : a 3-year outcome study.

Cardiac troponin T (cTnT), a highly sensitive and specific indicator of myocardial cell death, may be elevated in congestive heart failure (CHF). The aims of this study were to test the hypothesis that decompensated CHF may be associated with an increase in cTnT release and to correlate between cTnT levels and patient outcomes. The authors studied 55 patients aged between 38 and 86 years (30 women and 25 men) who were hospitalized for CHF. Left ventricular ejection fraction (EF) was calculated by using modified Simpsons rule by echocardiography. cTnT levels were assessed. Troponin T ≥0.1 ng/mL was considered as positive. All patients were contacted by phone annually during the next 3 years, and their history of subsequent hospital admissions and current health status were recorded. cTnT was negative in 44 (80%) and positive in 11 (20%) patients. EF was significantly lower and NYHA was higher in cTnT-positive patients. During the 3-year follow-up period, 25 patients died from CHF. The mortality rate was 8/11 (72.7%) among cTnT-positive patients, whereas the mortality rate was 17/44 (38.6%) among cTnT-negative patients. There were significant relationships among positivity of cTnT, NYHA, EF, and mortality rate. Multivariate regression analysis yielded an independent relationship between positivity of cTnT, NYHA classification, and mortality rate. The percent of hospital admissions due to CHF was also higher in patients with cTnT positive (63.6% versus, 27.3%, p <0.05). In conclusion, this study shows that cTnT positivity is an independent risk factor in predicting the long-term mortality and morbidity rate in patients with CHF. Patients with worsening CHF may possibly be identified early on the basis of their elevated serum cTnT levels.

Diastolic Function Predicts Outcome After Aortic Valve Replacement in Patients with Chronic Severe Aortic Regurgitation

Due to eccentric hypertrophy and fibrosis, patients with severe aortic regurgitation (AR) have diastolic dysfunction. Increased fibrosis correlates with increased myocardial stiffness and worsening of diastolic function. Patients with irreversible left ventricular (LV) dysfunction have severe myocardial fibrosis and myocyte apoptosis and do not benefit from aortic valve replacement (AVR).

Ultrasound Accelerated Thrombolysis May Be an Effective and Safe Treatment Modality for Intermediate Risk/Submassive Pulmonary Embolism

Pulmonary embolism (PE) is a potentially life-threatening condition and the fact that 90% of PE originate from lower limb veins highlights the significance of early detection and treatment of deep vein thrombosis. Massive/high risk PE involving circulatory collapse or systemic arterial hypotension is associated with an early mortality rate of approximately 50%, in part from right ventricular (RV) failure. Intermediate risk/submassive PE, on the other hand, is defined as PE-related RV dysfunction, troponin and/or B-type natriuretic peptide elevation despite normal arterial pressure. Without prompt treatment, patients with intermediate risk PE may progress to the massive category with a potentially fatal outcome. In patients with PE and right ventricular dysfunction (RVD), in hospital mortality ranges from 5% to 17%, significantly higher than in patients without RVD.

Hydatid disease presenting as cardiac tamponade : A case history

Although hydatid disease has been reported in almost all human tissues, cardiac involve ment is uncommon. The authors report a case of cardiac hydatid disease presenting with cardiac tamponade. The diagnostic value of transthoracic and transesophageal echocar diography, computed tomography, and angiography in hydatid heart disease is also discussed.

'Natural Conduit' between two atria associated with atrial septal defect.

Herein, we present a case of 46 years old woman with an extracardiac venous connection between two atria associated with secundum type atrial septal defect (ASD). This interatrial tunnel was not recognized by both transthoracic and transesophageal echocardiographic examinations. Computed tomography suspected a blood flow from right inferior pulmonary vein to inferior caval vein. Consequently, the patient underwent cardiac catheterization. Angiography revealed a tunnel between left and right atrium. To our knowledge, this is the first report of a case with venous tunnel between two atria associated with secundum type ASD in the literature.

Angina Pectoris Due to Severe Muscular Bridge in Hypertrophic Cardiomyopathy

We report the case of a 39-year-old male with hypertrophic cardiomyopathy who complained of angina pectoris. The patient was treated with a beta blocker and a calcium antagonist without effect. Myocardial scintigraphy revealed anterior ischemia. Cardiac catheterization and ventriculography revealed severe systolic narrowing of the left anterior descending coronary artery and no significant pressure gradient across the left ventricular outflow tract. Myotomy was performed on a muscular bridge over the left anterior descending coronary artery and the patients angina was relieved. In young patients with hypertrophic cardiomyopathy who develop angina refractory to medical therapy, a coexisting muscular bridge should be sought.

Renal Amyloidosis and Rheumatic Heart Disease

Tamer Tetiker, Department of Internal Medicine, Medical Faculty, Çukurova University, TR-Adana (Turkey) Dear Sir, Although amyloidosis secondary to collagen vascular diseases, in particular to Beh-çet’s disease [1], is frequently reported, rheumatic heart disease with amyloidosis is rare. Herein, we report a patient with mitral valve stenosis due to rheumatic heart disease and renal amyloidosis. A 40-year-old woman with a history of mitral stenosis and mitral valve commisuro-tomy performed 10 years before admission was referred to our hospital because of uremia. On physical examination, blood pressure was 110/60 mm Hg and heart rate 80 beats/min. On auscultation, a 2o/6 systolic murmur was determined along the left sternal border and lung fields were clear. The liver and spleen were nonpalpable. Hematocrit was 20% and WBC was 15,000/mm3, while BUN was found to be 50 mg/dl and serum creatinine level was 4.5 mg/dl. Erythrocyte sedimentation rate was 120 mm/h. Blood chemistry was otherwise normal. Creatinine clearence was 9 ml/min and proteinuria was 7 g/day. ECG showed sinus rythm with a negative terminal deflection of P wave in lead V], and nonspecific ST-T wave changes in the D2, D3 and AVF leads. Leftventriculer hypertrophy voltage criteria were present. Chest roentgenogram showed cardiac enlargement. Abdominal ultrasonographic examination demonstrated a reduction in kidney size and an increase in kidney echo pattern. Echocar-diography revealed an increase in leftventriculer wall thickness and mitral stenosis with dilatation of the left atrium. Renal biopsy demonstrated renal amyloidosis (AA). Diet, vitamin D, CaC03 and colchicine were initiated. The renal functions of the patient deteriorated rapidly, but she refused hemodi-alysis. She died because of septicemia at the end of the 1-year follow-up period. In our patient, the renal amyloidosis may have developed secondary to the present rheumatic heart disease or the cardiac pathology may be related to primary cardiac amyloid infiltration as a part of systemic amyloidosis. Amyloid infiltration of the heart may show several echocardiographic features as in our patients [2], but it is well-known that the diagnosis of cardiac amyloidosis cannot be assumed from the findings of amyloid in other organs and it may not rule out that diagnosis despite the absence of left-ventriculer hypokinesia and low-voltage ECG [3]. In addition, most of the amyloid lesions are limited to the atria and there may be involvement of valves and ventricles in only about one-third of the cases [4]. Furthermore, it may be concluded that a long-standing inflammatory process such as rheumatic heart disease can lead to secondary amyloidosis [5].