Berkten Berkalp

Obesity and left ventricular diastolic dysfunction

To assess the influence of obesity on left ventricular function, 20 obese women (mean body mass index (BMI) 33.8 +/- 3.1 kg/m2 and mean age 31.1 +/- 2.4 years) without evidence of heart disease were evaluated by echocardiography. Obese subjects had greater left ventricular mass index (103 +/- 22 g/m2, 76 +/- 18 g/m2; P < 0.0001) and augmented fractional shortening (39 +/- 2.6%, 36 +/- 0.1%; P < 0.0001) than normals. Isovolumic relaxation time was prolonged in the obese group (92 +/- 11 ms) as compared with the control group (76 +/- 11 ms; P < 0.0001). The ratio of peak early and atrial filling velocities was significantly lower (1.2 +/- 0.4, 1.9 +/- 0.6; P < 0.0001) and atrial contribution was higher (39 +/- 9, 25 +/- 5; P < 0.0001) in obese subjects than in normals. Shortened deceleration time was measured in obese subjects (142 +/- 30, 179 +/- 20 ms; P < 0.0001). In conclusion, obesity causes relaxation and early filling abnormalities and diastolic filling is compensated by augmented atrial contribution. Diastolic dysfunction is an early indicator of cardiac involvement in obesity.

Exercise-induced myocardial ischemia in patients with coronary artery ectasia without obstructive coronary artery disease

BACKGROUND Aetiology, clinical significance and treatment options for coronary artery ectasia/aneurysm is not clear. OBJECTIVE We sought to determine whether exercise can induce coronary ischemia in patients with coronary artery ectasia/aneurysm without significant coronary stenosis. METHODS Coronary artery ectasia was defined as 1.5-2-fold, aneurysm as >2-fold luminal dilatation of the adjacent normal segment. The study patients could have irregularities with ectatic coronaries but they did not have stenotic lesions >50% with visual assessment of two blinded observers. Patients having coronary artery ectasia or aneurysm with prior myocardial infarction, dilated cardiomyopathy, valvular heart disease, bundle branch block, significant ST-T changes were excluded. The control group was formed from a well matched population of 32 patients with normal coronary arteries who have not performed a treadmill test before coronary angiography. The study group underwent a symptom limited treadmill test if they did not have one before coronary angiogram, all control patients underwent treadmill test. RESULTS Thirty-three patients with coronary artery ectasia/aneurysm (ranging from one to three vessels) but without significant stenosis were derived from 4470 cardiac catheterization procedures between January 1998 and July 2000. In the study group, 17 of the patients had positive treadmill tests with respect to five patients in the control group (P = 0.004). In subgroup analysis, diffuse ectasia/aneurysm (involving 2-3 vessels) was found to be strongly related with ischemia (P = 0.005) with respect to local disease. CONCLUSION Coronary artery ectasia/aneurysm may lead to exercise induced ischemia, especially in the diffuse form.

Association between the severity of heart failure and the susceptibility of myocytes to apoptosis in patients with idiopathic dilated cardiomyopathy

BACKGROUND Bcl-2 proto-oncogene, an inhibitor of apoptosis and Bax proto-oncogene, an inducer of apoptosis play critical roles in the molecular circuit controlling apoptosis in cardiac muscle. The ratio of Bax to Bcl-2 proto-oncogene determines survival or death after an apoptotic stimulus. We speculated that susceptibility of myocytes to apoptosis determined as the Bax/Bcl-2 ratio might vary with the severity of heart failure. METHODS AND RESULTS We studied immunohistochemically 108 endomyocardial biopsy specimens from 30 patients with idiopathic dilated cardiomyopathy (mild heart failure, n=14; moderate or severe heart failure, n=16) with the use of Bcl-2 and Bax monoclonal antibodies. The expression of each protein was determined semiquantitatively as the fraction of myocytes labeled with specific monoclonal antibodies using a digital morphometric analysis system. Patients with mild heart failure showed significantly increased Bax/Bcl-2 ratio than the patients with advanced heart failure (1.59+/-1.26 vs. 0.34+/-0.43, P=0.002). The expression of Bcl-2 was found to be independent of the severity of heart failure whereas the expression of Bax was significantly higher in patients with mild heart failure compared to the patients with moderate or severe heart failure (52.1+/-29.3 vs. 21.6+/-22.4%, P=0.005). Additionally, Bax/Bac-2 ratio was inversely correlated with the mitral E-interventricular septum distance, left ventricular end-systolic and end-diastolic diameter. CONCLUSION The susceptibility of myocytes to apoptosis is significantly increased in the early phase of heart failure but it decreases with worsening of the disease due to depressed expression of Bax onco-protein. Increased myocyte susceptibility to apoptosis may have a role in the transition from mild heart failure to severe in patients with idiopathic dilated cardiomyopathy.

Analysis of high frequency QRS potentials observed during acute myocardial infarction

The value of high frequency QRS potentials (HFQRS) during acute myocardial infarction (AMI) was assessed to define infarct size and prognosis. HFQRS were recorded by signal-averaged ECG with 150-250 Hz frequency ranges, using X, Y, Z orthogonal leads. Recordings were obtained in surviving AMI patients (n = 33, 12 inferior, 11 anterior, 10 anterior-inferior) on the first and tenth days, but in non-survived patients (n = 5, 2 inferior, 1 anterior, 2 anterior-inferior) only on the first day. Additionally, the frequency of ventricular tachycardia (VT) was evaluated by 24-h Holter monitoring in all patients at the same days. The control group consisted of 11 healthy people. In surviving AMI patients, RMS voltage of vector magnitude reduced in anterior and anterior-inferior MI but filtered QRS duration was longer in inferior MI than normals (P < 0.05, < 0.05, < 0.01, respectively). In nonsurvived patients, RMS voltages of leads X, Y, Z and vector magnitude were lower than normals (P < 0.01, < 0.05, < 0.01, < 0.01, respectively) and surviving AMI patients (P < 0.01, < 0.05, < 0.05, < 0.05, respectively), the filtered QRS duration was found to be longer than normals and survived patients (P < 0.01, < 0.01). In patients who had VT on Holter monitoring, filtered QRS duration was significantly longer than in patients without VT (P < 0.05). As a result, HFQRS was important for defining infarct size but not malignant ventricular arrhythmias. VT was related to filtered QRS duration. HFQRS may offer significant prognostic information and contribute to early risk stratification of AMI patients.

Coronary artery aneurysm formation after balloon angioplasty and stent implantation.

This study describes coronary angiographic and intravascular ultrasound evaluation of late coronary artery aneurysms after percutaneous balloon angioplasty and bailout stent implantation. Intravascular ultrasound distinguishes true aneurysms from pseudoaneurysms. The discussion is focused on the etiology and prognosis of this rare complication.

Cardioinhibitory response to carotid sinus massage in patients with coronary artery disease.

The relationship between cardioinhibitory response to the carotid sinus massage and the severity of coronary artery lesions and left ventricular impairment was investigated in 86 patients who underwent coronary angiography. The study group (Group 1) comprised 63 patients who had coronary lesions and the control group (Group 2) comprised 23 patients who had normal coronary arteries. There was no significant relationship between the severity of coronary artery lesions and the cardioinhibitory response to the carotid sinus massage in the study group. However, there was a positive correlation (r = 0.478, P < 0.01) between total left ventricular segment scores and the maximal change in RR interval (%) during the right carotid sinus massage in the study group. During the right carotid sinus massage, maximal change of RR interval (%) was significantly higher in patients who had segmental wall motion abnormalities than in patients who did not (83.0 +/- 72.4% vs. 32.9 +/- 42.5%, P < 0.01, respectively). In the patients who could have echocardiographic measurements there was negative correlation between fractional shortening value and maximal change of RR interval (%) (right massage; r = -0.482, P < 0.01, left massage; r = -0.334, P < 0.05). In conclusion, we found a significant relationship between the cardioinhibitory response to carotid sinus massage and the presence and severity of the segmental wall motion abnormalities and left ventricular impairment in patients with coronary artery disease.

Significance of Dual Left Anterior Descending Coronary Artery in Interventional Cardiology A Case Report

The variants of the left anterior descending (LAD) coronary artery are important in inter pretation of coronary angiograms and in interventional procedures. The authors present a patient who had percutaneous transluminal coronary angioplasty and stent implanta tion to a presumed proximal LAD without the realization that dual LAD was present because of the total occlusion of the long LAD.

Importance of notching and slurring of the resting QRS complex in the diagnosis of coronary artery disease

Data on the correlation of coronary artery disease (CAD) and electrocardiographic findings are, except for Q waves, still controversial. The purpose of this study was to determine whether QRS complex notching and slurring (N&S) is of significant value as a diagnostic discriminator in the detection of CAD. This study comprised 500 consecutive patients aged between 24 and 81 years (mean, 53.4 years) who underwent coronary angiography because of chest pain. Patients were evaluated for CAD, angiographic evidence of myocardial infarction (MI), N&S, and abnormal Q waves. Of these 500 patients, 418 had CAD, and 370 of these had significant (> or = 70%) coronary artery obstruction. The remaining 82 patients had normal coronary arteries. The data revealed that the distribution of N&S in the patients with or without CAD was similar in both the inferior and limb leads (P > .05). But the percentage of N&S in more than two contiguous limb leads was higher in the patients with CAD than in the patients without CAD. Notching and slurring in at least one limb lead was found to be of no value in the diagnosis of MI, of wall motion abnormalities, and of significant obstruction. Notching and slurring in the anterior leads is more sensitive but less specific than abnormal Q waves in the same leads in the detection of significant obstruction, anterior MI, and anterior wall motion abnormalities. Notching and slurring in the anterior leads has as much importance as abnormal anterior Q waves in the detection of angiographic evidence of anterior infarct, of anterior wall motion abnormalities, and of significant coronary artery obstruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperhomocysteinaemia and coronary artery disease in the Turkish population

Objective — Many studies have demonstrated a strong association between elevated plasma total homocysteine (Hcy) levels and vascular disease.The objective of this study was to examine the relation between homocysteine levels and coronary artery disease in Turkish patients. Methods and results — In this study plasma homocysteine levels were measured in control and patient groups. A significant coronary artery lesion was defined as a stenosis of ≥70% as shown by coronary angiography and determined by on-line quantitative measurements; treatment was by coronary angioplasty. Total plasma Hcy level was measured before the coronary intervention. Plasma homocysteine levels were measured by an HPLC method in patients with a definite diagnosis of coronary artery disease and compared with age- and sex-matched controls. Patients with coronary artery disease had significantly higher mean homocysteine concentrations than control subjects (geometric mean ± 95% CI: 12.5±1.1 μmol/l vs. 8.60±1.07 μmol/l, p > 0.001). Eighty-three (59%) members of the patient group and 14 (21%) members of the control group had plasma homocysteine concentrations above the 11.3 μmol/l, which represents the concentration which includes the uppermost quintile of the control group distribution (odds ratio 4.35, 95% CI; 2.1-8.94). Conclusion — Results of this study indicate that high plasma levels of homocysteine in Turkish subjects are associated with coronary artery disease. Our data suggest that focusing public health initiatives on this issue may reduce the high prevalence of cardiovascular disease in the Turkish population.OBJECTIVE Many studies have demonstrated a strong association between elevated plasma total homocysteine (Hcy) levels and vascular disease. The objective of this study was to examine the relation between homocysteine levels and coronary artery disease in Turkish patients. METHODS AND RESULTS In this study plasma homocysteine levels were measured in control and patient groups. A significant coronary artery lesion was defined as a stenosis of > or = 70% as shown by coronary angiography and determined by on-line quantitative measurements; treatment was by coronary angioplasty. Total plasma Hcy level was measured before the coronary intervention. Plasma homocysteine levels were measured by an HPLC method in patients with a definite diagnosis of coronary artery disease and compared with age- and sex-matched controls. Patients with coronary artery disease had significantly higher mean homocysteine concentrations than control subjects (geometric mean +/- 95% CI: 12.5 +/- 1.1 micromol/l vs. 8.60 +/- 1.07 micromol/l, p<0.001). Eighty-three (59%) members of the patient group and 14 (21%) members of the control group had plasma homocysteine concentrations above the 11.3 micromol/l, which represents the concentration which includes the uppermost quintile of the control group distribution (odds ratio 4.35, 95% CI; 2.1-8.94). CONCLUSION Results of this study indicate that high plasma levels of homocysteine in Turkish subjects are associated with coronary artery disease. Our data suggest that focusing public health initiatives on this issue may reduce the high prevalence of cardiovascular disease in the Turkish population.

Effects of Percutaneous Transluminal Coronary Angioplasty on Late Potentials and High Frequency Mid-QRS Potentials

The high frequency mid-QRS potentials and late potentials are important in coronary artery disease because they are related to the extent of ischemia and prognosis. In this study, the effects of successful percutaneous transluminal coronary angioplasty (PTCA) on these potentials were evaluated. Twenty-four patients with coronary artery disease (aged 34-67 years, 5 women, 19 men) were examined. Eight of these patients had a history of myocardial infarction (4 anterior, 3 inferior, 1 anterior and inferior). Signal averaged ECG was recorded at 40- to 250-Hz frequency ranges for late potentials and 150- to 250-Hz frequency ranges for mid-QRS potentials before PTCA, and they were repeated 1 month later. The QRS duration (107.7 +/- 9.8 to 105.3 +/- 9.3 ms, p < 0.0001) root-mean-square voltage (39.4 +/- 20.1 to 47.7 +/- 22.2 microV, p < 0.00001) and low amplitude signal duration (30.7 +/- 9.9 to 27.7 +/- 9.3 ms, p < 0.001) showed significant changes in 40- to 250-Hz ranges before and after PTCA. The same results were also obtained in the 150- to 250-Hz frequency ranges: the QRS duration decreased (90.9 +/- 9.8 to 86.5 +/- 9.1 ms, p < 0.005) and the root-mean-square voltage increased (5.5 +/- 1.6 to 6.1 +/- 1.8 microV, p < 0.00001). Thus, successful PTCA causes improvement in late potential parameters, so the risk of malign arrhythmia that affects the prognosis can be reduced. Additionally, the increase in high frequency mid-QRS potentials shows the decrease in the ischemia after PTCA.