Aylin Yildirir

Epicardial adipose tissue thickness by echocardiography is a marker for the presence and severity of coronary artery disease

BACKGROUND AND AIM Epicardial adipose tissue (EAT), which is thought to be a component of visceral adiposity, is associated with the metabolic syndrome. We aimed to test the hypothesis that echocardiographic EAT thickness can be a marker for the presence and severity of coronary artery disease (CAD). METHOD AND RESULTS In all, 150 patients (100 patients with CAD and 50 patients with normal coronary arteries by diagnostic coronary angiography; 65 women, 85 men; mean age 55.7+/-7.4 years) were enrolled. EAT thickness was measured using 2-D echocardiographic parasternal long- and short-axis views. EAT thickness measurements were compared with angiographic findings. EAT thickness was significantly higher in patients with CAD in comparison to those with normal coronary arteries (6.9+/-1.5 mm vs. 4.4+/-0.8 mm; P<0.001). Furthermore, EAT thickness increased with the severity of CAD (multivessel disease 7.4+/-1.2 mm vs. single vessel disease 5.7+/-1.7 mm; P<0.001). Gensinis score significantly correlated with EAT thickness (r=0.600, P<0.001). EAT thickness of > or = 5.2 mm had 85% sensitivity and 81% specificity (ROC area 0.914, P<0.001, 95% CI [0.86-0.96]) for predicting CAD. CONCLUSION EAT thickness, which is easily and non-invasively evaluated by transthoracic echocardiography, can be an adjunctive marker to classical risk factors for the prediction of CAD.

Diagnosis and management of inadvertently placed pacing and ICD leads in the left ventricle: a multicenter experience and review of the literature.

Three patients from different centers with pacemaker or ICD leads endocardially implanted in the left ventricle are described. All leads, two ventricular pacing leads and one ICD lead, were inserted through a patent foramen ovale or an atrial septum defect. The diagnosis was made 9 months. 14 months, and 16 years, respectively, after implantation. All patients had right bundle branch block configuration during ventricular pacing. Chest X ray was suggestive of a left‐sided positioned lead except in the ICD patient. Diagnosis was confirmed with echocardiography in all patients. One patient with a ventricular pacing lead presented with a transient ischcmic attack at 1‐month postimplantation. During surgical repair of the atrial septum defect 14 months later, the lead was extracted and thrombus was attached to the lead despite therapy with aspirin. The other patients were asymptomatic without anticoagulation (9 months and 16 years after implant). No thrombus was present on the ICD lead at the time of the cardiac transplantation in one patient. We reviewed 27 patients with permanent leads described in the literature. Ten patients experienced thromboembolic complications, including three of ten patients on antiplatelet therapy. The lead was removed in six patients, anticoagulation with warfarin was effective for secondary prevention in the four remaining patients. In the asymptomatic patients, the lead was removed in five patients. In the remaining patients, 1 patient was on warfarin, 2 were on antiplatelet therapy, and in 3 patients the medication was unknown. After malposition was diagnosed, three additional patients were treated with warfarin. In conclusion, if timely removal of a malpositioned lead in the left ventricle is not preformed, lifelong anticoagulation with warfarin can be recommended as the first choice therapy and lead extraction reserved in case of failure or during concomitant surgery.

Diastolic dysfunction and increased serum homocysteine concentrations may contribute to increased cardiovascular risk in patients with polycystic ovary syndrome

OBJECTIVE To assess cardiac flow parameters in patients with polycystic ovary syndrome (PCOS). DESIGN A prospective case-control study. SETTING University-based hospital. PATIENT(S) Thirty consecutive patients with PCOS were enrolled. Thirty women with regular menstrual cycles served as the controls. INTERVENTION(S) Systolic and diastolic function parameters were assessed by standard two-dimensional and M-mode echocardiography. Insulin sensitivity was evaluated by a standard 75-g oral glucose tolerance test and area-under-curve insulin analysis. Serum hormones, lipid profile, homocysteine, vitamin B(12), folate, fibrinogen, uric acid, and plasminogen activator inhibitor-I concentrations were measured. MAIN OUTCOME MEASURE(S) Systolic and diastolic function parameters, insulin sensitivity and serum homocysteine levels. RESULT(S) The mean serum homocysteine and uric acid concentrations were significantly higher in the PCOS group. Patients with PCOS had significant hyperinsulinemia. All systolic function parameters were comparable between the two groups. However, patients with PCOS had significantly lower peak mitral flow velocity in early diastole and significantly lower ratio between the early and late peak mitral flow velocities and also had significantly longer isovolumic relaxation time, reflecting a trend for nonrestrictive-type diastolic dysfunction. The area-under-curve insulin correlated positively with peak mitral flow velocity in late diastole (r = 0.375). The mean cholesterol/high-density lipoprotein ratio correlated negatively with mean mitral flow velocity in early diastole (E) peak (r = -0.474). The mean fasting insulin level correlated negatively with mean E/A ratio (r = -0.387). CONCLUSION(S) Diastolic dysfunction and increased serum homocysteine concentrations may contribute to increased cardiovascular disease risk in patients with PCOS.

Effects of menstrual cycle on cardiac autonomic innervation as assessed by heart rate variability.

Objective: The aim of the study was to investigate the effects of menstrual cycle on cardiac autonomic function parameters in young healthy women by means of heart rate variability (HRV).

Melatonin levels decrease in type 2 diabetic patients with cardiac autonomic neuropathy

Abstract:  The present study has been designed to determine melatonin levels in type 2 diabetic patients and test the relationship between the autonomic nervous system and melatonin dynamics. Thirty‐six type 2 diabetic patients and 13 age‐matched healthy subjects were recruited for the study. Circadian rhythm of melatonin secretion was assessed by measuring serum melatonin concentrations between 02:00–04:00 and 16:00–18:00 hr. Melatonin dynamics were re‐evaluated with respect to autonomic nervous system in diabetic patients with autonomic neuropathy who were diagnosed by the cardiovascular reflex tests, heart rate variability (HRV), and 24‐hr blood pressure monitoring. Nocturnal melatonin levels and the nocturnal melatonin surge were low in the diabetic group (P = 0.027 and 0.008 respectively). Patients with autonomic neuropathy revealed decreased melatonin levels both at night and during day when compared with healthy controls (P < 0.001 and 0.004 respectively) while the melatonin dynamics were similar to controls in patients without autonomic neuropathy. Nocturnal melatonin level was positively correlated with nocturnal high and low frequency components of HRV (P = 0.005 and 0.011 respectively) and systolic and diastolic blood pressures at night (P = 0.002 and 0.004 respectively) in patients with autonomic neuropathy. We found a negative correlation between nocturnal melatonin levels and the degree of systolic blood pressure decrease at night (r = −0.478, P = 0.045). As a conclusion this study has shown that circadian rhythm of melatonin secretion is blunted in type 2 diabetic patients and there is a complex relationship between various components of autonomic nervous system and melatonin secretion at night. Among the patients with autonomic neuropathy those with more preserved HRV and the systolic nondippers (<10% reduction in blood pressure during the night relative to daytime values) have more pronounced melatonin surge at night.

Heart Rate Variability in Young Women with Polycystic Ovary Syndrome

Background: Limited data are available related to the effects of sex hormones on cardiac autonomic function. Few studies investigated the heart rate variability (HRV) parameters during regular menstrual cycle or in postmenopausal women using hormone replacement therapy, but the results were contradictory. The aim of the study was to compare the characteristics of the autonomic innervation of the heart in polycystic ovary syndrome (PCOS) patients with regularly cycling controls.

Echocardiographic Evidence of Cardiac Involvement in Ankylosing Spondylitis

Abstract: Aortic insufficiency, myocardial fibrosis and conduction disturbances are known complications of ankylosing spondylitis (AS). However, few studies have assessed left ventricular diastolic function and no data are available about P-wave analysis. In this study 88 AS patients and 31 healthy volunteers underwent clinical examination, electrocardiography, echocardiography and signal-averaged P-wave analysis for the evaluation of asymptomatic cardiac involvement. The aortic root in AS patients was larger and this was correlated with the duration of the disease. Five of 88 AS patients (5.7%) had evidence of mitral valve prolapse, six (6.8%) had thick and redundant mitral valves without prolapse, five (5.7%) had mild mitral regurgitation, two had moderate (2.3%) and two had mild (2.3%) aortic regurgitation. Examination of diastolic function revealed a lower peak of E-wave velocity (E) and E/A ratio, a higher peak of A-wave velocity (A) and acceleration rate of the A wave, a longer deceleration time of E-wave velocity and isovolumic relaxation time in the AS group compared to controls. Mean filtered P-wave duration (PWD) in AS was similar to that of controls. However, PWD in AS patients was positively correlated with left atrial dimension and acceleration rate of the A wave and negatively correlated with E and E/A ratio. In conclusion, cardiac involvement may be seen in AS patients in the absence of clinical manifestations. Echocardiographic examination of diastolic function can be used in this asymptomatic period. Further studies are needed to clarify the prognostic significance of diastolic abnormalities and the value of P-wave analysis in cardiac evaluation of these patients.

Impaired coronary microvascular function and increased intima-media thickness in rheumatoid arthritis

BACKGROUND Rheumatoid arthritis (RA) is associated with excessive cardiovascular mortality. Recently, some studies have shown endothelial dysfunction in RA patients with high inflammatory activity. In addition, it has been suggested that the chronic inflammatory state of RA contributes to accelerated atherosclerosis. Therefore, we aimed to evaluate whether coronary microvascular dysfunction and increased carotid artery intima-media thickness exist in patients with a long history and well controlled disease activity of RA lacking traditional cardiovascular risk factors. METHODS Thirty RA patients (22 women; mean age 43.7+/-9.0) and 52 healthy volunteers (38 women; mean age 45.3+/-5.4) were included into the study. Using transthoracic echocardiography, each subject underwent echocardiographic examination including coronary flow reserve (CFR) and carotid intima-media thickness (IMT) measurement. RESULTS CFR values were statistically reduced for RA patients as compared to controls (2.4+/-0.5 vs. 2.7+/-0.4, P=0.002) whereas IMT values were significantly increased (0.6+/-0.1 vs. 0.5+/-0.1, P=0.001). In RA patients, CFR positively correlated with lateral Em/Am ratio (r=0.399, P=0.029), and negatively correlated with lateral isovolumic relaxation time (IVRT) (r=-0.744, P=0.005), IMT (r=-0.542, P=0.002) and RA disease duration (r=-0.495, P=0.005). Reflecting LV diastolic function, mitral E-wave deceleration time and isovolumic relaxation time were borderline significant between the groups, however lateral Em/Am ratio and lateral IVRT were statistically different. CONCLUSIONS Patients with RA had impaired CFR and increased carotid IMT, and these injurious effects correlated significantly with disease duration.

Prediction of atrial fibrillation recurrence after cardioversion by P wave signal-averaged electrocardiography

The purpose of this report was to determine prospectively whether P wave signal-averaged electrocardiography (ECG) is useful for the prediction of recurrences of atrial fibrillation after cardioversion. The P wave signal-averaged ECG was recorded in 73 patients after successful cardioversion. Duration of the filtered P wave and the root mean square voltages for the last 20 ms of the P wave were calculated. In addition to signal-averaged ECG P wave analysis, all patients were evaluated by echocardiography. During 6 months follow-up period recurrence of atrial fibrillation was observed in 31 (42.5%) patients and in 42 (57.5%) patients sinus rhythm was maintained. There was no difference in gender, age, presence of organic heart disease, left atrial diameter, left ventricular ejection fraction, use of antiarrhythmic drug, and duration of atrial fibrillation (P>0.05). The filtered P-wave duration was longer and the root mean square voltages for the last 20 ms of the P wave was lower in patients with recurrence of atrial fibrillation than in patients who maintained sinus rhythm (138.3+/-12.5 ms vs. 112.4+/-11.8 ms, P = 0.001; 1.9+/-0.7 microV vs. 2.5+/-0.6 microV, P = 0.001). A filtered P-wave duration > or =128 ms associated with a root mean square voltage for the last 20 ms of the P wave < or =2.1 microV had a sensitivity of 70% and specificity of 76% for the detection of patients with recurrence of atrial fibrillation after successful cardioversion of atrial fibrillation. We found that the likelihood of recurrence of atrial fibrillation after cardioversion was increased 4.31-fold (95% confidence interval 2.08-9.83) if these parameters were used. These results suggest that P wave signal-averaged ECG could be useful to identify patients at risk for recurrence of atrial fibrillation after cardioversion.

Prevention of contrast-induced impairment of renal function by short-term or long-term statin therapy in patients undergoing elective coronary angiography

A decline in kidney function after contrast exposure is associated with a high risk of morbidity and mortality during hospitalization and over long-term periods. Several retrospective and recent prospective clinical trials have shown that statin therapy might prevent contrast-induced nephropathy in patients undergoing percutaneous coronary intervention. In this study, we aimed to assess the effects of statin therapies on renal function parameters in patients undergoing elective coronary angiography. One hundred and sixty patients undergoing elective coronary angiography were randomized equally into two groups: atorvastatin 40 mg/day group (statin started 3 days before coronary angiography) and an untreated control group. An additional 80 patients were included as a chronic statin therapy group. Serum creatinine, serum cystatin C, and glomerular filtration rate (GFR) were measured before and 48 h after coronary angiography. Cockcroft–Gault and Modification of Diet in Renal Disease (MDRD) equations were used to determine GFR. After coronary angiography, serum creatinine and GFR determined by MDRD were significantly better in patients using atorvastatin than those in controls (P = 0.002 and P = 0.004, respectively). Postprocedure serum creatinine, cystatin C, and GFR determined by MDRD were also significantly better in chronic statin therapy group than those in controls (P = 0.006, P = 0.003, and P = 0.004, respectively). There were no differences in renal function parameters between the short-term atorvastatin group and the chronic statin therapy group. Our data demonstrate that the use of short-term atorvastatin and chronic statin therapy may have a role in protecting renal function after elective coronary angiography.