Davran Çiçek

Hematologic Parameters and Angiographic Progression of Coronary Atherosclerosis

Hematologic parameters have prognostic importance in cardiovascular disease. However, the relation between atherosclerosis progression and hematologic parameters is not well defined. A total of 394 patients requiring repeat coronary angiography were included in the study. According to angiography, patients were divided into 2 groups, progressive (n = 196) and nonprogressive (n = 198) diseases. Hematologic parameters including mean platelet volume (MPV) and neutrophil/lymphocyte (N/L) ratio were measured. Glucose, creatinine, and cholesterol were significantly higher in the progressive group. Mean platelet volume count was similar in both groups. The N/L ratio was significantly higher in the progressive group (5.0 ± 5.1 vs 3.2 ± 3; P = .001). In multivariate analysis, the N/L ratio was significantly related with progression (relative risk [RR]: 2.267, 95% CI: 1.068-4.815, P = .03). Progression rate was significantly high in patients with high N/L ratio (39% vs 56%). Our results suggest that the N/L ratio is a predictor of progression of atherosclerosis.

Incidence, clinical characteristics, and 4-year follow-up of patients with isolated myocardial bridge: a retrospective, single-center, epidemiologic, coronary arteriographic follow-up study in southern Turkey ☆

INTRODUCTION Myocardial bridge is a rare coronary anomaly that is generally considered to be benign. The true incidence and long-term prognosis are still under debate. Therefore, we investigated the prevalence and prognosis of patients with isolated myocardial bridge in our center. METHOD This study is a retrospective, angiographic follow-up which includes 14,250 patients. Median follow-up was 4 years. The typical angiographic finding of myocardial bridging (MB) is systolic narrowing of an epicardial artery. Exclusion criterion was myocardial bridge with coronary artery disease (CAD). The primary end point was major cardiac events (death, myocardial infarction, and revascularization). RESULTS Myocardial bridge was observed in 118 (0.83%) patients without CAD. The median age was 56.2. There were 30 (25.5%) male and 88 (74.5%) female patients. The arterial segment that was most frequently involved was the left anterior descending artery, as evident in 91 patients (77.2%). Most of the myocardial bridge produces a systolic narrowing between 30% and 50%. There was no major adverse cardiac event nor a need for any revascularization in the follow-up period with medical treatment. CONCLUSION Isolated myocardial bridge is a benign and rare coronary anomaly. However, further studies are needed to detect long-term prognosis.

Effect of Obstructive Sleep Apnea on Heart Rate, Heart Rate Recovery and QTc and P-wave Dispersion in Newly Diagnosed Untreated Patients

Introduction:Obstructive sleep apnea syndrome (OSAS) is associated with autonomic dysfunction, whereas increased heart rate (HR), HR recovery time (HRR-1), QT-corrected interval (QTc) and P-wave dispersion (Pd) are associated with cardiovascular events. The aim of the current investigation was to clarify the influence of OSAS severity on these cardiac parameters. Methods:Ninety newly diagnosed and untreated patients with OSAS underwent overnight polysomnography and cardiopulmonary exercise testing, including HRR-1, echocardiography, 24-hour Holter electrocardiography, surface electrocardiogram (ECG) and measurement of several metabolic parameters. The patients were divided into the following 4 groups: 26 with apnea-hypopnea index (AHI) <5, 20 with 5 ⩽ AHI <15, 20 with 15 ⩽ AHI <30 and 24 with AHI ≥30. QTc and Pd were calculated in all leads of the surface ECG. Mean HR was measured using 24-hour Holter ECG, and HRR-1 was measured using cardiopulmonary exercise testing. Results:QTc was increased in patients with moderate-to-severe OSAS. Pd was significantly increased in patients with OSAS compared with those without OSAS. In addition, Pd was correlated with AHI and associated with the severity of disease. Mean HRs over a period of 24 hours during wakefulness and sleep correlated significantly with AHI and the lowest SpO2 in patients with OSAS, whereas HRR-1 was inversely correlated with the severity of OSAS, as expressed by AHI. Conclusion:We showed that HR, Pd, HRR-1 and QT-corrected time are correlated with OSAS severity. Further studies are required in order to investigate the prognostic effect of HRR-1, Pd, HR and QTc in OSAS.

Effects of Three Month Nasal Continuous Positive Airway Pressure Treatment on Electrocardiographic, Echocardiographic and Overnight Polysomnographic Parameters in Newly Diagnosed Moderate/Severe Obstructive Sleep Apnea Patients

The objective of the study was to determine the effects of nasal continuous positive airway pressure (nCPAP) therapy on left ventricular (LV) function and electrocardiographic parameters in newly diagnosed moderate/severe obstructive sleep apnea (OSA) patients without cardiovascular comorbidities and medical treatments. We examined 44 patients who underwent overnight polysomnography together with 24-hour Holter electrocardiography, cardiopulmonary exercise testing including heart rate recovery at 1 minute (HRR-1), echocardiography, surface electrocardiography, and those who were diagnosed with moderate/severe OSA apnea--hypopnea index ≥ 15. After 3 months of nCPAP treatment, the above-mentioned examinations were repeated. Forty-four patients completed the treatment period. Twelve weeks on effective nCPAP induced a significant increase in the mitral E/A ratio (P = 0.001), as well as reductions in isovolumic relaxation time (P = 0.001) and mitral deceleration time (DT) (P = 0.002). There were no significant differences in LV ejection fraction, LV mass index, and pulsed wave Doppler parameters. Mean heart rate was 79.2 ± 12.5 pulses/minute, maximum P-wave duration 117.5 ± 8.6 msec, P-wave dispersion (PWd) 54.6 ± 10.2 msec, corrected QT interval (QTc) 436.5 ± 40.5 msec, and QT dispersion (QTd) 46.3 ± 7.1 msec, which significantly decreased to 70.4 ± 9.6 pulses/minute (P < 0.001), 111.5 ± 8.7 msec (P < 0.001), 51.6 ± 8.9 msec (P < 0.001), 418.4 ± 31.2 msec (P < 0.001), and 33.8 ± 3.4 msec (P < 0.001), respectively. Exercise capacity at baseline determined as 10.5 ± 2.2 metabolic equivalents (METS) and HRR-1 (20.6 ± 11.7 bpm) significantly increased (12.1 ± 1.5 METS and 27.4 ± 8.6 bpm). There was no significant difference in aortic root parameters. Three-month nCPAP therapy significantly increased LV shortening fraction, with no effect on systolic function or aortic root diameters and a positive effect on heart rate, PWd, HRR-1, QTc and QTd time following nCPAP therapy.

Obstructive Sleep Apnoea and Its Association with Left Ventricular Function and Aortic Root Parameters in Newly Diagnosed, Untreated Patients: A Prospective Study

This prospective study investigated whether untreated obstructive sleep apnoea-hypopnoea syndrome (OSAHS), which is strongly associated with cardiovascular disease, is a risk factor for left ventricular (LV) systolic and diastolic dysfunction and aortic root dilatation. Ninety consecutive patients with breathing and snoring problems, including 64 with newly diagnosed, untreated OSAHS, were classified into four groups based on their apnoea-hypopnoea index (AHI). All participants underwent overnight polysomnographic and complete echocardiographic examinations, and LV systolic, diastolic and aortic measurements were compared. Body mass index was the only demographic characteristic that significantly increased as the severity of OSAHS (AHI) increased and it significantly correlated with AHI. Patients with a higher AHI had a significantly higher aortic root diameter and aortic stiffness index, and significantly lower aortic strain. The LV diastolic parameters were least favourable in patients with more severe OSAHS. The LV ejection fraction did not differ significantly between groups. It was concluded that LV diastolic function and aortic elastic parameters deteriorate with OSAHS.

Hyperhomocysteinemia in a young woman presenting with acute myocardial infarction: Case report

Homocysteine (Hcy), a sulfur-containing amino acid that is formed by demethylation of dietary methionine to cystein. Elevated homocysteine level is known to be associated with coronary artery disease. We present a case of acute myocardial infarction in a 25-year-old woman, associated with hyperhomocysteinaemia. Her other risk factors for coronary artery disease were smoking, a moderately high LDL level, and a family history of sudden cardiac death. This case illustrates the need to include plasma homocysteine measurement in the setting of acute coronary syndromes in women with premature atherosclerosis, even in the presence of traditional risk factors for coronary artery disease.

Which is responsible for cardiac autonomic dysfunction in non-diabetic patients with metabolic syndrome: Prediabetes or the syndrome itself?

AIMS Cardiac autonomic dysfunction (CAD) is associated with both prediabetes and metabolic syndrome (MS). Heart rate variability (HRV) and heart rate turbulence (HRT) are reliable 24-h Holter-ECG findings of cardiac autonomic function. This study aimed to investigate the relation between MS and its components and CAD using HRV and HRT. MATERIALS AND METHODS The study included 80 non-diabetic patients with MS and 70 control subjects. All study population and the patients with MS were further analyzed for each diagnostic component of MS to investigate which criteria impaired HRV and HRT. RESULTS HRV and HRT parameters were disturbed in patients in the MS group. While impairment in HRV and HRT was significantly related to the presence of the fasting plasma glucose (FPG) criterion, there were no differences between groups in terms of the other 4 MS criteria. Moreover, FPG level was significantly correlated with SDNN (r=-0.352, p<0.001), SDNN index (r=-0.423, p<0.001), SDANN (r=-0.301, p<0.001), RMSSD (r=-0.237, p<0.001), pNN50 (r=-0.237, p<0.001), turbulence onset (TO) (r=0.365, p<0.001) and turbulence slope (TS) (r=-0.365, p<0.001). Among the MS diagnostic criteria, only FPG level was an independent determinant of all HRV and HRT parameters. CONCLUSIONS This study confirms the relation between MS and CAD. Increased FPG alone appears to be responsible for the mentioned findings among the 5 diagnostic criteria. Accordingly, CAD may be the result of prediabetes, not MS in patients with MS.

Cardiac autonomic nervous dysfunction detected by both heart rate variability and heart rate turbulence in prediabetic patients with isolated impaired fasting glucose

Objective: Cardiac autonomic nervous dysfunction (CAND), a severe complication of diabetes, has also been shown to affect prediabetic patients. The role of isolated impaired fasting plasma glucose (IFG), a subtype of prediabetes, is not clear in the pathogenesis of CAND. The aim of this study was to examine the relationship between isolated IFG and cardiac autonomic function using heart rate variability (HRV) and heart rate turbulence (HRT) indices derived from 24-h Holter–electrocardiogram recordings. Methods: This observational, prospective, cross-sectional study examined 400 consecutive subjects divided into three groups according to oral glucose tolerance test results: the control group [Group I, fasting plasma glucose (FPG) <100 mg/dL and normal glucose tolerance, n=193], the isolated IFG group (Group II, FPG ≥100 and <126 mg/dL, n=134), and the isolated impaired glucose tolerance (IGT), both IFG and IGT, or newly diagnosed diabetes’ group (Group III, n=73). Patients with non-sinus rhythm, known diabetes mellitus, coronary artery disease, heart failure, severe valvular disease, or receiving medical therapy that may affect HRV and HRT indices were excluded. Time domain HRV parameters, turbulence onset (TO), turbulence slope (TS), and HRT category were examined. Chi-square, one-way analysis of variance, Kruskal–Wallis H, and Mann–Whitney U tests were used to compare variables where appropriate. The correlation between Holter data and FPG levels was analyzed using the Spearman’s test. Multiple linear regression analysis was performed to identify independent predictors of the HRV and HRT parameters. Results: Median (interquartile range 25–75) FPG levels in Groups I, II, and III were 89 (83/93) mg/dL, 109 (104/116) mg/dL, and 174 (150.5/197) mg/dL, respectively. There were significant differences in HRV and HRT parameters between and among all groups. While HRV parameters and TS decreased from Group I to Group III, TO and HRT category gradually increased. Additionally, FPG level was significantly correlated with SDNN, r=–0.220; SDNN index, r=–0.192; SDANN, r=–0.207; RMSSD, r=–0.228; pNN50, r=–0.226; TO, r=0.354; and TS, r=–0.331 (all p<0.001). Conclusion: CAND, as detected by both HRV and HRT, appear to be present in the isolated IFG subtype of prediabetes.

Successful treatment of massive pulmonary embolism with reteplase

Unexpected and unexplained out-of-hospital cardiac arrests have a poor prognosis. Difficulties encountered during the differential diagnosis phase may delay the administration of specific treatment for treatable and reversible causes of cardiac arrest. Massive pulmonary embolism is a reversible cause of cardiac arrest, but without proper management it has a high mortality rate. Presently described is the case of a 53-year-old female patient with a massive pulmonary embolism.

Predictors of neurologically favorable survival among patients with out-of-hospital cardiac arrest: A tertiary referral hospital experience

I read with great interest the original article written by Balcı et al. published in the April 2017 issue of the journal[1] about out-of-hospital cardiac arrest victims and factors predicting neurologically favorable survival. Out-of-hospital cardiac arrests have poor clinical outcomes despite medical improvements, and even with proper cardiopulmonary resuscitation interventions offered in current guidelines, survival rates remain low.[2] With on-going cardiopulmonary resuscitation, it is vital to search for the treatable and reversible causes of cardiac arrest. Physicians should be aware of every clue that may be related to the patient’s collapse. It is a challenging situation to make a differential diagnosis at the time of on-going cardiopulmonary resuscitation and interventions, but some clinical findings can be helpful. As proof of this low rate of definitive diagnosis, Balcı et al. reported 58.1% unknown diagnosis related to out-of-hospital cardiac arrests.[1] Usually, we do not have enough time to correct our possible differential diagnosis, and we have to manage out-of-hospital cardiac arrest patients depending on “most probable differential diagnosis.” This kind of management can direct us to a faster specific treatment choice while cardiopulmonary resuscitation is going on. Initial heart rhythm can give us that kind of chance for management. Balcı et al. reported asystole as initial rhythm on monitor at first sight in 97 of patients out of 129 victims.[1] However, in a recently published paper investigating initial heart rhythm in out-of-hospital cardiac arrest victims, asystole as initial rhythm was reported to be as low as 34%, and even lower in bystander-witnessed cases.[3] This difference in asystole as initial rhythm may be related to prolonged transportation time, as reported in the article by Balcı et al.,[1] and may be even greater case percentage when there is no witness. Yamaguchi et al. also reported that pulseless electrical activity or shockable first rhythm, such as ventricular tachycardia/ventricular fibrillation, has a more favorable clinical outcome.[3] In a report previously published,[4] it was also suggested that initial rhythm can guide physicians in the possible differential diagnosis. In this report, ischemic coronary events were found to be more related to initial rhythms of asystole and ventricular arrhythmias. Interestingly, the authors suggested that witnessed, atraumatic, out-of-hospital cardiac arrest with initial rhythm of pulseless electrical activity is most probably related to massive pulmonary embolism. Also in this paper, the authors claimed that pulseless electrical activity is somehow a neurologically more favorable clinical presentation than other initial rhythms, such as asystole.[4] Physicians and emergency ambulance service medical staff dealing with out-of-hospital cardiac arrest victims should evaluate initial heart rhythm on monitor promptly for possible differential diagnosis and to decide on specific treatment of reversible etiological factors of cardiac arrest. Initial heart rhythm can be a strong predictor of neurological outcome in survivors of out-of-hospital cardiac arrest.