Erkan Ayhan

Neck circumference as a measure of central obesity: Associations with metabolic syndrome and obstructive sleep apnea syndrome beyond waist circumference

BACKGROUND & AIMS To investigate the relationship of neck circumference (NC) to metabolic syndrome (MetS) and obstructive sleep apnea syndrome (OSAS) and whether it adds information to that provided by waist circumference. METHODS Cross-sectional analysis of a population sample of 1,912 men and women, aged 55.1 +/- 12 years, representative of Turkish adults. MetS was identified based on modified criteria of the ATP-III, OSAS when habitual snoring and episodes of apnea were combined with another relevant symptom. RESULTS NC measured 36.7 (+/- 3.5) cm in the total sample. It was significantly correlated with numerous risk factors, above all body mass index and waist girth (r > or = 0.6), homeostatic model-assessed insulin resistance, blood pressure and, inversely, with smoking status and sex hormone-binding globulin. Sex- and age-adjusted NC was associated significantly with MetS, at a 2-3-fold increased likelihood for 1 standard deviation (SD) increment. After further adjustment for waist circumference and smoking status, a significant residual odds ratio (OR, 1.13 [95% CI 1.08; 1.19]) persisted, corresponding to ORs of 1.53 and 1.27 in males and females, respectively, for 1 SD increment. Even when adjusted for all MetS components, a residual OR (1.08 [95% CI 1.000; 1.17]) remained. Sex- and age-adjusted NC was associated significantly also with OSAS in genders combined, independent of waist girth, yielding an added OR of 1.3 for 1 SD increment. CONCLUSIONS NC contributes to MetS likelihood beyond waist circumference and the MetS components. Regarding association with OSAS, NC is of greater value than WC among Turkish men, not women.

Red cell distribution width as a novel prognostic marker in patients undergoing primary angioplasty for acute myocardial infarction.

ObjectivesRed cell distribution width (RDW), a measure of red blood cell size heterogeneity, was evaluated in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). BackgroundHigher RDW is associated with mortality in patients with symptomatic cardiovascular disease, heart failure, and also in the general population. We hypothesized that admission RDW would be predictive of adverse outcomes in patients after primary PCI. MethodsTwo thousand five hundred and six consecutive STEMI patients (mean age 56.6±11.8 years; 2075 males, 431 females) undergoing primary PCI were retrospectively enrolled into this study. Admission RDW was measured as part of the automated complete blood count. Patients were grouped as elevated or nonelevated RDW using the upper limit of normal value of 14.8% and were followed for in-hospital and long-term outcomes for a mean period of 1.8±1.3 years (median 21 months). ResultsA higher in-hospital mortality rate was observed among patients with elevated admission RDW (mean 16.1±1.6%) compared with those with nonelevated RDW (mean 13.4±0.8%) (7.6 vs. 3.6%, P<0.001). The long-term cardiovascular prognosis was worse for patients with elevated admission RDW (Kaplan–Meier, log-rank P<0.001). We used Cox proportional hazard models to examine the association between RDW and adverse clinical outcomes. After discharge, there were 129 deaths during follow-up. A significant association was noted between elevated admission RDW level and the adjusted risk of cardiovascular mortality (hazard ratio: 1.831, 95% confidence interval: 1.034–3.24, P=0.03). In addition, elevated admission RDW was also an independent predictor of cardiovascular mortality in the nonanemic subpopulation of patients (hazard ratio: 2.703, 95% confidence interval: 1.208–6.048, P=0.016). ConclusionA high admission RDW level in patients with STEMI undergoing primary PCI was associated with increased risk for in-hospital and long-term cardiovascular mortality.

Prognostic Value of Uric Acid in Patients With ST-Elevated Myocardial Infarction Undergoing Primary Coronary Intervention

Elevated uric acid (UA) levels have been associated with cardiovascular disease in epidemiologic studies. The relation between UA levels and long-term outcomes in patients with ST-segment elevation myocardial infarction who undergo primary percutaneous coronary intervention is not known. Data from 2,249 consecutive patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention were evaluated. Patients were divided into 2 groups with high or low UA using upper limits of normal of 6 mg/dl for women and 7 mg/dl for men. There were 1,643 patients in the low-UA group (mean age 55.9 ± 11.6 years, 85% men) and 606 patients in the high-UA group (mean age 60.5 ± 12.6 years, 76% men). Serum UA levels were 8.0 ± 1.5 mg/dl in the high-UA group and 5.2 ± 1.0 mg/dl in the low-UA group (p <0.001). The in-hospital mortality rate was significantly higher in patients with high UA levels (9% vs 2%, p <0.001), as was the rate of adverse outcomes in patients with high UA. The mean follow-up time was 24.3 months. Cardiovascular mortality, reinfarction, target vessel revascularization, heart failure, and major adverse cardiac events were all significantly higher in the high-UA group. In a multivariate analyses, high plasma UA levels were an independent predictor of major adverse cardiac events in the hospital (odds ratio 2.03, 95% confidence interval 1.25 to 3.75, p = 0.006) and during long-term follow-up (odds ratio 1.64, 95% confidence interval 1.05 to 2.56, p = 0.03). In conclusion, high UA levels on admission are independently associated with in-hospital and long-term adverse outcomes in patients with ST-segment elevation myocardial infarction who undergo primary percutaneous coronary intervention.

Impaired protection against diabetes and coronary heart disease by high-density lipoproteins in Turks

The issue of whether or not incident type 2 diabetes mellitus and coronary heart disease (CHD) can be predicted by high-density lipoprotein (HDL) cholesterol in both sexes needs investigation. A representative sample of 3035 middle-aged Turkish adults free of CHD at baseline was studied with this purpose prospectively over a mean of 7.8 years. High-density lipoprotein cholesterol levels were found to be correlated in women positively with plasma fibrinogen and weakly with waist girth and C-reactive protein, and to be not correlated with fasting insulin. High-density lipoprotein cholesterol protected men against future CHD risk (for a 12-mg/dL increment: relative risk = 0.80 [95% confidence interval, 0.69-0.95]) after multivariable adjustment in logistic regression analyses for age, smoking status, physical activity grade, hypertension, abdominal obesity, diabetes, and lipid-lowering drugs. However, men were not protected against risk of diabetes. In women, HDL cholesterol was not associated with risk for CHD, whereas intermediate (40-60 mg/dL) compared with lower HDL cholesterol levels proved protective against risk of diabetes (relative risk = 0.57 [95% confidence interval, 0.36-0.90]) after adjustments that included apolipoprotein A-I tertiles. Yet higher serum concentrations failed to yield protection against diabetes. It was concluded that HDL particles confer partially lacking protection against cardiometabolic risk among Turks, and this impairment is modulated by sex. This highly important observation may result from a setting of prevailing chronic subclinical inflammation.

Relation of red cell distribution width with the presence, severity, and complexity of coronary artery disease.

ObjectivesRed cell distribution width (RDW) is a measure of the heterogeneity of cell size in the peripheral blood and has been shown to be an independent correlate of adverse outcomes in healthy participants and in some cardiac conditions. We examined the association between RDW and the complexity of coronary artery disease (CAD). MethodsThe study population included 193 nonanemic patients who had undergone coronary angiography for stable angina pectoris. Baseline RDW was measured as part of the automated complete blood count. Patients were classified depending on whether the SYNTAX score was 0 (no angiographically apparent CAD) or at least 1 where CAD was present angiographically. ResultsPatients with angiographic CAD had significantly elevated RDW levels compared with the patients without CAD (14.4±1.3 vs. 12.5±0.9, P<0.001). There was a good correlation between RDW and the SYNTAX score (r=0.55, P<0.001). In a receiver operating characteristic curve analysis, an RDW value of 13.25 was identified as an effective cut-point in the segregation of the presence or absence of CAD [area under curve=0.87, 95% confidence interval (CI) 0.81–0.92]. An RDW value of more than 13.25 yielded a sensitivity of 84%, a specificity of 79%, a positive predictive value of 89%, and a negative predictive value of 71%. In multivariate analysis, RDW was observed to be an independent predictor for both angiographic CAD (odds ratio=4.80, 95% CI 2.41–9.57, P<0.001) and for a high (>32) SYNTAX score (odds ratio=2.28, 95% CI 1.45–3.60, P=0.01). ConclusionRDW is a readily available clinical laboratory value that is associated with both the presence and the complexity of CAD.

Serum γ‐Glutamyltransferase: Independent Predictor of Risk of Diabetes, Hypertension, Metabolic Syndrome, and Coronary Disease

Serum γ‐glutamyltransferase (GGT) is associated with oxidative stress and hepatic steatosis. The extent to which its value in determining incident cardiometabolic risk (coronary heart disease (CHD), metabolic syndrome (MetS), hypertension and type 2 diabetes) is independent of obesity needs to be further explored in ethnicities. After appropriate exclusions, a cohort of 1,667 adults of a general population (age 52 ±11 years) was evaluated prospectively at 4 years follow‐up using partly Cox proportional hazard regressions. GGT activity was measured kinetically, and values were log‐transformed for analyses. MetS was identified by Adult Treatment Panel‐III criteria modified for male abdominal obesity. Median (interquartile range) GGT activity was 24.9 (17.0; 35.05) U/l in men, 17.0 (12.3; 24.0) U/l in women. In linear regression analysis, while smoking status was not associated, (male) sex, sex‐dependent age, alcohol usage, BMI, fasting triglycerides and C‐reactive protein (CRP) were significant independent determinants of circulating GGT. Each 1‐s.d. increment in (= 0.53 ln GGT) GGT activity significantly predicted in each sex incident hypertension (hazard ratio (HR) 1.20 (95% confidence interval (CI) 1.10; 1.31)), and similarly MetS, after adjustment for age, alcohol usage, smoking status, BMI and menopause. Strongest independent association existed with diabetes (HR 1.3 (95% CI 1.1; 1.5)) whereas GGT activity tended to marginally predict CHD independent of total bilirubin but not of BMI. Higher serum total bilirubin levels were protective against CHD risk in women. We conclude that elevated serum GGT confers, additively to BMI, risk of hypertension, MetS, and type 2 diabetes but only mediates adiposity against CHD risk.

The impact of admission red cell distribution width on the development of poor myocardial perfusion after primary percutaneous intervention

BACKGROUND The purpose of this study was to evaluate the predictive value of red cell distribution width (RDW) on the electrocardiographic no-reflow phenomenon in patients undergoing primary percutaneous coronary intervention (PCI). METHODS One-hundred consecutive patients (mean age 61.3 ± 12.8 years and male 77%) with ST-elevation myocardial infarction, who were treated with primary PCI, were analyzed prospectively. RDW and high sensitive C reactive protein (hs-CRP) were measured. The sum of ST-segment elevation was obtained immediately before and 60 min after the restoration of coronary flow. The difference between two measurements was accepted as the amount of ST-segment resolution and was expressed as ∑STR. ∑STR < 50% was accepted as electrocardiographic sign of no-reflow phenomenon. RESULTS There were 30 patients in the no-reflow group (Group 1) and 70 patients in the normal re-flow group (Group 2). RDW and hs-CRP levels on admission were higher in Group 1. An RDW level ≥14% measured on admission had 70% sensitivity and 64% specificity in predicting no-reflow on ROC curve analysis. Mid-term cardiovascular events were significantly higher in Group 1. In multivariate analyses, RDW (OR 2.93, <95% CI 1.42-6.04; p = 0.004), and tirofiban (OR 0.16, <95% CI 0.05-0.48; p = 0.001) were independent predictors of no-reflow, and RDW (OR 5.89, <95% CI 1.63-21.24; p = 0.007), and creatine kinase-MB (CK-MB) on admission (OR 1.01, <95% CI 1.00-1.02; p = 0.006) were independent predictors of mid-term mortality. CONCLUSIONS A greater baseline RDW value was independently associated with the presence of electrocardiographic no-reflow.

The relationship between red blood cell distribution width and the clinical outcomes in non-ST elevation myocardial infarction and unstable angina pectoris: a 3-year follow-up.

ObjectivesRed blood cell distribution width (RDW), a marker of variation in the size of the circulating red blood cells, was evaluated in patients with non-ST elevation myocardial infarction (NSTEMI) and unstable angina pectoris (UAP). BackgroundHigher RDW is associated with mortality in the general population, particularly in those with symptomatic cardiovascular disease, and heart failure. We hypothesized that admission RDW might be predictive of adverse clinical outcomes for patients with NSTEMI and UAP. MethodsWe prospectively enrolled 310 patients with NSTEMI and UAP (mean age 59.3±11.9 years; 236 men, 74 women) in this study. Admission RDW was measured and the study population was classified on the basis of RDW tertiles. A high RDW (n=95) was defined as a value in the upper third tertile (>14%) and a low RDW (n=215) was defined as any value in the lower two tertiles (⩽14%). The patients were followed up for clinical outcomes for up to 3 years after discharge. ResultsIn the Kaplan–Meier survival analysis, the 3-year mortality rate was 19% in the high RDW group versus 5.6% in the low RDW group (P<0.001). In the receiver operating characteristic curve analysis, an RDW value of more than 14% yielded a sensitivity of 60% and a specificity of 72.5%. A significant association was found between a high admission RDW level and the adjusted risk of cardiovascular mortality (hazard ratio: 3.2, 95% confidence interval: 1.3–7.78, P=0.01). ConclusionRDW is a readily available clinical laboratory value associated with long-term cardiovascular mortality in NSTEMI and UAP.

Smoking inhibits visceral fat accumulation in Turkish women Relation of visceral fat and body fat mass to atherogenic dyslipidemia, inflammatory markers, insulin resistance, and blood pressure

We investigated among sexes the associations of visceral adipose tissue area (VAT) and body fat mass with smoking status, atherogenic dyslipidemia, inflammatory markers, insulin resistance, and blood pressure (BP). A random sample of the Turkish adult population consisting of 157 middle-aged men and women was evaluated cross-sectionally and partly prospectively. Although men were not influenced significantly, smoking vs never-smoking women had 4 years later a lower VAT (by 31 cm(2), P = .005). Fat mass was significantly correlated with homeostasis model, C-reactive protein, and BP in both sexes, although not with atherogenic dyslipidemia as was VAT. Compared with men, women had lower VAT (P < .01) and, because of interaction of sex and smoking (P = .06), tended to be less susceptible to accumulation of VAT per kilogram body fat mass. In linear regression models comprising 7 variables, VAT was associated in men with systolic BP, apolipoprotein B, and C-reactive protein (each P = .04) and was associated in women with age, smoking status, and high-density lipoprotein cholesterol (each P <or= .01). Significant positive correlations of VAT were obtained with future systolic BP in either sex (P < .03). Body fat mass and visceral fat accumulation are inhibited by cigarette smoking in women. Markers of insulin resistance and inflammation are independently associated with visceral fat marginally in women but significantly in men. Visceral fat is better associated than fat mass with atherogenic dyslipidemia and, in men, with apolipoprotein B. Thus, sex interacts with the dynamics of cardiometabolic risk.

Predictive value of neutrophil to lymphocyte ratio in clinical outcomes of non-ST elevation myocardial infarction and unstable angina pectoris: a 3-year follow-up.

We sought to determine the prognostic value of neutrophil to lymphocyte ratio (NLR) in non-ST elevation myocardial infarction (NSTEMI) and unstable angina pectoris (UAP). A total of 308 (mean age 59.22 ± 11.93) patients with NSTEMI and UAP were prospectively evaluated. The study population was divided into tertiles based on admission NLR values. The patients were followed for clinical outcomes for up to 3 years after discharge. In the Kaplan-Meier survival analysis, 3-year mortality was 21.6% in patients with high NLR versus 3% in the low-NLR group (P < .001). In a receiver–operating characteristic curve analysis, an NLR value of 3.04 was identified as an effective cut point in NSTEMI and UAP of a 3-year cardiovascular mortality (area under curve [AUC] = 0.86, 95% confidence interval [CI] 0.8-0.92). An NLR value >3.04 yielded a sensitivity of 79% and specificity of 71%. Admission NLR is the strong and independent predictor of a 3-year cardiovascular mortality in patients with NSTEMI and UAP.