Cengiz Sabanoglu

Prolonged Tp-e interval and Tp-e/QT correlates well with modified Rodnan skin severity score in patients with systemic sclerosis

BACKGROUND Ventricular arrhythmias can be seen in systemic sclerosis (SSc) patients and are thought to be a result of fibrosis or ischemia of the ventricular myocardium. Tp-e interval and Tp-e/QT ratio are electrocardiographic (ECG) indices to predict ventricular tachyarrhythmia and cardiovascular mortality. We aimed to evaluate Tp-e interval and Tp-e/QT ratio in patients with SSc. METHODS A total of 107 patients with SSc (mean age, 48.6 ± 14.0 years; 96 females) and 100 healthy controls (mean age, 49.4 ± 8.6 years; 90 females) were enrolled. The standard 12-lead ECG was recorded; QTc, Tp-e interval and Tp-e/QT ratio were measured. Modified Rodnan skin severity score (MR-SSS) calculated for all SSc patients. RESULTS Tp-e interval (90.7 ± 23.8 ms vs. 84.0 ± 20.6 ms, p = 0.032) and Tp-e/QT ratio (0.20 ± 0.05 vs. 0.18 ± 0.04, p = 0.007, respectively) were significantly prolonged in SSc patients than in the control group. Pearsons correlation analyses revealed positive correlations of MR-SSS with QTc (r = 0.427, p = 0.001), Tp-e interval (r = 0.620, p = 0.001) and Tp-e/ /QT ratio (r = 0.615, p = 0.001). MR-SSS (b = 2.108, p = 0.001) and CRP (b = 2.273, p = 0.027) were found to be significant independent predictors of Tp-e interval. Similarly, MR-SSS (b = 0.004, p = 0.001) was only a significant independent predictor of Tp-e/QT ratio among patients with SSc. CONCLUSIONS The patients with SSc had a prolonged Tp-e interval and Tp-e/QT ratio compared with normal subjects. Furthermore, this prolongation was well correlated with clinical severity score among patients with SSc. Ventricular repolarization dispersion as a predictor of ventricular arrhythmias was found to be diminished in patients with SSc. Patients with SSc, particularly with higher MR-SSS, should be followed closely for adverse cardiovascular outcomes.

Assessment of cardiac autonomic functions by heart rate recovery indices in patients with myocardial bridge

BACKGROUND Heart rate (HR) recovery (HRR) reflects autonomic activity and predicts cardiovascular events. The aim of this study was to assess HRR in patients with myocardial bridge (MB). METHODS Medical recordings of 93 patients with MB and appropriate age, compared to 78 sex-matched healthy subjects were analyzed. MB was diagnosed via coronary computed tomography angiography after a positive exercise stress test (EST). HRR indices were calculated by subtracting 1st (HRR1), 2nd (HRR2) and 3rd (HRR3) minute HR from the maximal HR during EST. RESULTS HRR1 (30.2 ± 13.3 bpm vs. 35.8 ± 10.4 bpm, p = 0.001) and HRR2 (52.3 ± 13.3 bpm vs. 57.1 ± 11.6 bpm, p = 0.013) were lower in patients with MB. In addition, HRR1 was lower in patients with left anterior descending (LAD) MB than non-LAD MB (28.5 ± 13.2 vs. 37.1 ± 11.4, p = 0.013). Presence of MB, deep MB, LAD MB and multi-vessel MB were predictors of HRR1 (p < 0.01 for all). In a multivariate analysis, LAD MB was the only significant independent predictor of HRR1 (b = -8.524, p = 0.009). CONCLUSIONS Patients with MB have impairment in HRR indices which is more pronounced among patients with LAD MB. Cardiac autonomic dysfunction in MB might be due to recurrent myocardial ischemia.

Cardiac autonomic evaluation in breast cancer patients: role of cytokines and heart rate recovery

We read with great interest the recent article entitled “Cardiac autonomic modulation impairments in advanced breast cancer patients” by Arab et al. [1] in your distinguished journal. In their well-designed paper, the authors compared cardiac autonomic modulation in early versus advancedstage breast cancer patients before any type of cancer treatment and investigated associated factors. They evaluated cardiac modulation by heart rate variability (HRV) and assessed factors of anxiety, depression, physical activity, and other detailed clinical parameters. The advanced-stage cancer group had lower vagal modulation than early stage and benign pathologies; also, the advanced-stage group had lower overall HRV compared to benign conditions. Authors concluded that vagal cardiac autonomic modulation is inversely associated with breast cancer staging. In addition, they suggested implementation of HRV analysis in baseline assessment and clinical follow-up of cardiac monitoring in cancer patients. We have two comments and contributions regarding this issue. First, we suggest the authors to include serum cytokines in their future studies about cardiac autonomic evaluation in breast cancer. Cytokines are highly inducible secretory proteins that mediate intercellular communication in the immune system [2, 3]. They are grouped into several protein families which are referred to as tumor necrosis factors, interleukins, interferons, and colony-stimulating factors. The cytokines interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α) and interleukin-1 beta (IL-1β) are critical mediators of the inflammatory response. Inflammation correlates with increased invasiveness and poor prognosis in many types of cancer, including breast cancer. Numerous studies have also linked these cytokines to breast cancer progression [2–4]. The cross-talk between the immune system and the brain relies, therefore, not only on classical humoral pathways, but also substantially on recently discovered neural pathways [5, 6]. Vagal afferent sensory fibers play a vital role in the communication between body and brain when inflammation is occurring. Cytokines stimulate vagal afferents and IL-1, IL-6, and tumor necrosis factor-α (TNFα), correlate negatively with different HRV parameters of parasympathetic activity [5, 6]. The immune system is a still underestimated physiological and pathophysiological determinant of HRV dynamics. Thus, it would be better to include the levels of cytokines in a study evaluating the cancer stages and cardiac autonomic indices. As a second comment, it would be interesting to assess heart rate recovery (HRR) in this study. HRR after graded exercise is one of the commonly used techniques which reflect autonomic activity [7]. HRR indices show the rate of decline in the heart rate (HR) after the cessation of exercise test and are defined as HR difference between the maximal HR on exercise and the HR during recovery phase. An attenuated HRR, which is defined as the inadequate decline in HR immediately after exercise, reflects reduced parasympathetic activity [8]. The decline in HR during recovery is principally due to a reactivation of parasympathetic activity, mostly in the early recovery period [7]. HRR indices have been identified as a powerful and independent predictor of cardiovascular and all-cause mortality in healthy adults, in those with cardiovascular diseases and systemic disorders. Currently, the most common method used to detect anthracycline-induced cardiotoxicity is the evaluation of functional parameters by echocardiography. Detection of anthracycline-induced cardiotoxicity at an early stage is still disputed. We have ongoing research assessing HRR indices * Sercan Okutucu sercanokutucu@yahoo.com

Systemic Low-Grade Inflammation and Cardiovascular Disease in Systemic Lupus Erythematosus

We read with interest the recent article entitled “Association of Resting Heart Rate With Arterial Stiffness and LowGrade Inflammation in Women With Systemic Lupus Erythematosus” by Vargas-Hitos et al. In their prospective cross-sectional study, they reported that higher resting heart rate (RHR) is associated with higher arterial stiffness and systemic low-grade inflammation (SLGI) in women with systemic lupus erythematosus (SLE), independent of age, smoking, physical inactivity, systolic blood pressure, disease activity, and other cardiovascular (CV) disease risk factors. They also suggested that their study extends current knowledge on the association of RHR with arterial stiffness and SLGI in a population with SLE and at an increased risk of CV disease. Systemic lupus erythematosus is a chronic autoimmune disease, and recent findings have further strengthened the critical role of SLE-related immune dysregulation and metabolic disturbances in promoting accelerated CV disease. Moreover, RHR and markers of SLGI such as C-reactive protein (CRP), fibrinogen, and erythrocyte sedimentation rate (ESR) were shown to be associated with arterial stiffness and inflammation and these factors also strongly predispose to CV disease and all-cause mortality. In previous studies, it has been shown that the levels of CRP, fibrinogen, and ESR were significantly higher in infectious diseases. However, Vargas-Hitos et al did not mention whether acute or chronic infectious disease was the exclusion criterion in their study. Besides, how did the authors ensure the exclusion of infection in the presence of very high CRP and ESR levels? Another important issue, many easily available and reliable inflammatory and oxidative biomarkers such as white blood cell, neutrophil, lymphocyte, monocyte, platelet, mean platelet volume, and red cell distribution width have been demonstrated to be independent risk factors and prognostic markers for both inflammatory and CV disease. Therefore, the authors should have provided details about these biochemical laboratory parameters, clinical data, or imaging tools. As a final comment, it is crucial to know the SLE Disease Activity Index and the rates of anti-inflammatory or immunosuppression medication usage between the study groups for interpretation of the study findings. However, there is also no any data regarding this information in the study.

Inflammatory Biomarkers for Predicting High SYNTAX and SYNTAX II Scores

We read the recent article entitled “Assessment of relationship between C-reactive protein to albumin ratio and coronary artery disease severity in patients with acute coronary syndrome” by Cagdas et al with great interest. They demonstrated that the inflammatory status, reflected by the decreased albumin level, increased C-reactive protein (CRP) level, and higher CRP to albumin ratio (CAR), was closely associated with severe coronary artery disease (CAD) determined using the synergy between percutaneous coronary intervention with TAXUS and cardiac surgery (SYNTAX) and SYNTAX II scores. Moreover, they indicated that decreased albumin and increased CAR were independent predictors of high SYNTAX and SYNTAX II scores. SYNTAX score, which was established during the SYNTAX trial, is a helpful tool for treatment decisions regarding the complexity of the (CAD). SYNTAX II provides greater prognostic accuracy in clinical settings for patients with CAD and acute myocardial infarction. Endothelial dysfunction, oxidative stress, and many inflammatory biomarkers play a crucial role in the formation and progression of atherosclerosis. Many easily available inflammatory and oxidative biomarkers including red cell distribution width, platelet to lymphocyte ratio, neutrophil to lymphocyte ratio, monocyte to high-density lipoprotein cholesterol ratio, serum total bilirubin, serum uric acid, and serum vitamin D have been demonstrated to be independent risk factors and novel prognostic markers for the extent, severity, and complexity of CAD and cardiovascular events. In their study, Cagdas et al did not report data regarding these easily available hematological and biochemical parameters related to inflammation and oxidative stress. In addition, there was no information regarding medication usage. Finally, the multivariate logistic regression analysis lacks these parameters. So, the study findings regarding independent predictors of a high SYNTAX and SYNTAX II scores may be misleading. In conclusion, we believe that the combined information of multiple inflammatory biomarkers could be useful and more accurate for predicting the severity of CAD.

Are Endocan and Ischemia-Modified Albumin Reliable Biomarkers for Endothelial Dysfunction in Type 2 Diabetes Mellitus?

We read the article entitled “Association of Endocan, Ischemia-Modified Albumin, and hsCRP Levels With Endothelial Dysfunction in Type 2 Diabetes Mellitus” by Balamir et al with great interest. This prospective study reported that the indicators of endothelial dysfunction, endocan, and ischemia-modified albumin (IMA) were positively correlated with carotid intima-media thickness and 24-hour urine protein excretion. Moreover, endocan and IMA were independent risk factors for endothelial dysfunction in patients with type 2 diabetes mellitus (T2DM). Endothelial cell-specific molecule 1 (endocan) and IMA play a role in endothelial dysfunction as mediators of systemic inflammation and oxidative stress, and they are associated with cardiovascular (CV) disease and CV mortality. It has also been shown that serum endocan and IMA levels were significantly higher in infectious and other chronic diseases. Balamir et al did not mention whether acute or chronic infectious disease was an exclusion criterion in their study. Besides, how did the authors ensure the exclusion of infection in the presence of elevated serum high-sensitivity C-reactive protein (hsCRP) level (Table 4; maximum hsCRP level was 187.53 mg/L in the diabetic patients with endothelial dysfunction). Another important issue is that many easily available and reliable inflammatory and oxidative biomarkers such as white blood cell, neutrophil, lymphocyte, monocyte, red cell distribution width, erythrocyte sedimentation rate, and serum total bilirubin have been demonstrated to be independent risk factors and prognostic markers of endothelial dysfunction. Therefore, the authors should have provided details about at least some of these biochemical laboratory parameters as well as clinical data or imaging tools that may be needed when reaching a definitive diagnosis. It is important for clinicians to decide whether increased serum endocan and IMA levels are due to T2DM or other reasons, including infection. As a final query, was there a positive correlation of hsCRP level with endocan and IMA levels? In conclusion, serum endocan and IMA may be independent risk factors for endothelial dysfunction among patients with T2DM. However, confounding factors should be considered when interpreting these levels. ORCID iD

PP-127 Atrial Fibrillation in Healthy Young Adult after Vodka Red Bull Consumption

The Relation of MADIT ICD Score with Long Trem Cardiovascular Events in Patients with Implantable Cardioverter Defibrilator. Abdulkadir Uslu, Selim Topcu, U gur Aksu, Kamuran Kalkan, Oktay Gulcu, Ibrahim Halil Tanbo ga, Enbiya Aksakal, Serdar Sevimli. Department of Cardiology, Ahi Evren Training and Research Hospital, Trabzon, Turkey; Department of Cardiology, Ataturk University, Erzurum, Turkey; Department of Cardiology, Malkara Hospital, Tekirda g, Turkey.