Esmeray Acartürk

ESC Working Group on Valvular Heart Disease Position Paper: assessing the risk of interventions in patients with valvular heart disease

AIMS Risk scores provide an important contribution to clinical decision-making, but their validity has been questioned in patients with valvular heart disease (VHD), since current scores have been mainly derived and validated in adults undergoing coronary bypass surgery. The Working Group on Valvular Heart Disease of the European Society of Cardiology reviewed the performance of currently available scores when applied to VHD, in order to guide clinical practice and future development of new scores. METHODS AND RESULTS The most widely used risk scores (EuroSCORE, STS, and Ambler score) were reviewed, analysing variables included and their predictive ability when applied to patients with VHD. These scores provide relatively good discrimination, i.e. a gross estimation of risk category, but cannot be used to estimate the exact operative mortality in an individual patient because of unsatisfactory calibration. CONCLUSION Current risk scores do not provide a reliable estimate of exact operative mortality in an individual patient with VHD. They should therefore be interpreted with caution and only used as part of an integrated approach, which incorporates other patient characteristics, the clinical context, and local outcome data. Future risk scores should include additional variables, such as cognitive and functional capacity and be prospectively validated in high-risk patients. Specific risk models should also be developed for newer interventions, such as transcatheter aortic valve implantation.

Effects of apolipoprotein E genotypes and other risk factors on the development of coronary artery disease in Southern Turkey.

BACKGROUND Apolipoprotein E (apoE) plays a major role in lipoprotein metabolism and lipid transport. Associations between apoE genotypes, coronary artery disease (CAD) and other risk factors have been described by many investigators. The aim of this study was to investigate the role of apoE gene polymorphism and other risk factors in the development of CAD in subjects whose coronary arteries were evaluated by means of coronary angiography. METHODS The study population consisted of 199 subjects (114 male and 55 female). Of the total, 107 had CAD. The apoE gene was amplified by polymerase chain reaction (PCR) and then digested by CfoI restriction enzyme. The plasma lipid levels and other risk factors were also determined in all subjects. RESULTS The epsilon2 and epsilon4 allele frequencies and genotypes carrying epsilon4 allele were significantly higher in CAD (+) patients. Plasma lipids except triglycerides were increased in CAD (+) cases. We found that apoE genotypes, HT, DM, male gender, age and smoking were the independent predictors of CAD. There was no association between apoE alleles and lipids. CONCLUSION We conclude that apoE polymorphism (presence of epsilon4 allele) is associated with the development of CAD in Southern Turkey. In our study, we did not observe any effect of apoE alleles on lipid levels.

Clinical characteristics influence left and right ventricular diastolic function in healthy individuals.

The aim of this study was to determine whether clinical characteristics have an influence on left (LV) and right ventricular (RV) diastolic function indices measured by echocardiography in healthy individuals. Five hundred and three volunteers (253 women and 250 men) aged 18-66 years (mean 36.9 ±11.9) who were normotensive and free of clinically apparent heart disease were included in the study. Mitral and tricuspid peak E wave and A wave velocities, E/A ratio, deceleration time (DT) of the E wave, and left ventricular isovolumetric relaxation time (IVRT) were evaluated as left and right ventricular diastolic function indices. In order to determine the effects of age, gender, body surface area (BSA), waist/hip ratio (WHR), and heart rate (HR) on left and right ventricular diastolic function indices Students t test and correlation and linear regression analysis were used. IVRT and deceleration time of the mitral E wave (DTm) were significantly longer in men. Mitral and tricuspid A wave velocities, tricuspid E/A ratio, and decel eration time of the tricuspid E wave (DTt) were similar in both genders. Mitral and tricuspid E wave velocities and mitral E/A ratio were greater in women. Mitral E wave velocity and IVRT mostly correlated with WHR. Age was found to be the most important factor affecting mitral A wave velocity, DTm, E/A ratio, and right ventricular diastolic function indices. This study shows that age, heart rate, body surface area, and waist/hip ratio have important correlations with Doppler echocardiographic diastolic indices in normal individuals and should be consid ered in the evaluation of LV and RV diastolic function.

Comparison of the Effects of Warfarin and Heparin on Bleeding Caused by Dental Extraction: A Clinical Study

PURPOSE Replacement of warfarin with heparin for dental extractions in patients on long-term warfarin therapy is associated with wasted time, consumed labor, and increased treatment expenses. The aim of this study was to evaluate the safety of dental extraction without altering the warfarin regimen in patients with an international normalized ratio from 1 to 4. PATIENTS AND METHODS Forty patients who underwent tooth extraction were divided into 4 groups: continuation of warfarin without interruption (group 1), warfarin bridged with low-molecular-weight heparin (group 2), warfarin bridged with unfractionated heparin (group 3), and a control group of healthy individuals (group 4). Total amount of bleeding (milligrams) was measured for 20 minutes after tooth extraction. International normalized ratio values on the operative day and number of extra gauze swabs used for bleeding control in the first 48 hours were recorded for each patient. Results were statistically analyzed by analysis of variance, Fisher least-significant difference post hoc test, Pearson correlation, χ(2) test, and Student t test. RESULTS Mean amounts of bleeding were 2,486 ± 1,408; 999 ± 425; 1,288 ± 982; and 1,736 ± 876 mg for groups 1, 2, 3, and 4, respectively. There was no severe postoperative bleeding in any patient and the number of used extra gauze swabs did not differ significantly among groups. CONCLUSION With the aid of local hemostatic agents, dental extraction in patients receiving warfarin who have an international normalized ratio from 1 to 4 could be carried out without a significant risk of bleeding and without altering the anticoagulant regimen.

Tissue doppler imaging and NT-proBNP levels show the early impairment of ventricular function in patients with beta-thalassaemia major.

ß-thalassaemia major is a chronic haemolytic anaemia, and congestive heart failure (CHF) is the most common cause of death in this disease. N terminal pro B type natriuretic peptide (NT-proBNP) increases with the severity of CHF and predicts the prognosis. The aim of this study was to investigate the relation between left ventricular systolic and diastolic function determined by standard pulsed wave Doppler (PWD), tissue Doppler imaging (TDI) and NT-proBNP in patients with ß-thalassaemia major. Thirty-four patients with ß-thalassaemia major and 34 healthy individuals were included in the study. Blood samples were taken for NT-proBNP. All patients and controls underwent echocardiographic examination. All cardiac chambers were significantly increased in the patient group. Left and right ventricular (LV, RV) ejection fractions and all diastolic parameters were normal in the patients and controls.Tissue Doppler imaging (TDI) showed a significant decrease in LV and RV Sm velocities in patients compared to the controls. NT-proBNP levels were also significantly higher in the patient group. There was a negative correlation between serum NT-proBNP levels and LV Sm and RV Sm velocities in patients (r=-0.426, P=0.006 and r=-0.409, P=0.009, respectively). Linear regression analysis showed that LV Sm and RV Sm were independent predictors for NT-proBNP. Our findings suggest that although iron overload in patients with ß-thalassaemia major impairs the systolic and diastolic functions of both ventricles, it impairs the systolic function earlier than diastolic function. Tissue Doppler imaging is an easy and reliable method in the early determination of ventricular dysfunction in these patients.

Frequency of diastolic dysfunction in patients with sickle cell anaemia : a tissue Doppler imaging study

Objective — Although cardiac dilatation and systolic dysfunction have been well documented as a late manifestation, there are conflicting reports regarding the diastolic dysfunction, by using traditional echocardiographic methods in patients with sickle cell anaemia (SCA).The aim of this study was to investigate left ventricular diastolic function in SCA patients without congestive heart failure by using pulsed wave tissue Doppler imaging (TDI). Methods — Thirty-one patients (18 men and 13 women, mean age: 26.4 ± 8.5 years) with homozygous SCA without congestive heart failure and 31 healthy control subjects (19 men and 12 women, mean age: 26.5 ± 7.6 years) were enrolled in the study. All patients and the controls underwent echocardiographic examination. Left ventricular diastolic function was evaluated by using both traditional pulsed wave Doppler (PWD) and TDI. Results —The cardiac chamber dimensions, wall thicknesses, E and A transmitral peak diastolic velocities, systolic (Sm), early (Em) and late (Am) diastolic myocardial velocities were significantly increased in the patients compared to the controls. Diastolic dysfunction was found in 7 (22.6%) and 3 (9.7%) patients by PWD and TDI, respectively. Of the 7 patients with diastolic abnormalities, 4 patients with a restrictive pattern by PWD were found to be normal by TDI. Conclusion — Our results show that left ventricular diastolic dysfunction is not a frequent finding in patients with SCA without congestive heart failure and TDI is a more reliable and easy method to evaluate diastolic function. Patients with a restrictive pattern found by PWD should be reevaluated by using TDI.

Apolipoprotein E polymorphism in childhood nephrotic syndrome.

Abstract Recent clinical reports have demonstrated that the progression and prognosis of renal diseases are possibly influenced by apolipoprotein E (apoE) genotypes and alleles. In this study we investigated whether apoE genotypes and alleles can be a prognostic criterion for the steroid responsiveness in childhood nephrotic syndrome. One hundred and seven pediatric patients with primary idiopathic nephrotic syndrome and 83 healthy volunteers were enrolled in the study. Eighty-seven of the patients had steroid-sensitive nephrotic syndrome (SSNS) and 20 had steroid-resistant nephrotic syndrome (SRNS). The ɛ2 allele frequency and ɛ2/3 genotype frequency of the SNRS group were statistically higher when compared with SSNS and control groups (P<0.05). The higher frequency of the ɛ2 allele in steroid resistant nephrotic patients suggests that the ɛ2 allele gives a possible genetic predisposition to steroid resistance in our population, but further studies are needed to clarify this subject.

The prognostic value of arterial stiffness in systolic heart failure

BACKGROUND Increased arterial stiffness is an indicator of mortality. This study consists of an 18-month follow-up of the mortality in advanced heart failure patients with increased arterial stiffness. METHODS The study followed up 98 patients with a diagnosis of heart failure in NYHA class III and IV (76 males, 22 females and mean age of 60 ± 12 years) with a left ventricular ejection fraction ≤ 35% as determined by the Simpson method. Augmentation index (Aix) and pulse wave propagation velocity (PWV) parameters were used as indicators of arterial stiffness. Aix and PWV values were measured by arteriography. RESULTS 36 patients died. Both Aix and PWV were powerful determinants of mortality, independent of other prognostic variables (p = 0.013, OR: 0.805; p = 0.025, OR: 0.853). A cutoff value for Aix of -14.33 gave 91.2%, 80.3% sensitivity and specificity. A cutoff value for PWV of 11.06 gave 82.4%, 65.4% sensitivity and specificity mortality was predicted. Left ventricular ejection fraction (p = 0.008, OR: 0.859) and B-type natriuretic peptide (p = 0.01, OR: 0.833) was the other independent determinant of mortality. A significant difference was found in both Aix and PWV between the compensated measurements and decompensated heart failure measurements made in 70 patients (p = 0.035, p = 0.048). CONCLUSIONS Measurement of arterial stiffness is a convenient, inexpensive and reliable method for predicting mortality in patients with advanced heart failure.

Evaluation of arterial stiffness for predicting future cardiovascular events in patients with ST segment elevation and non-ST segment elevation myocardial infarction.

Background. Arterial stiffness parameters in patients who experienced MACE after acute MI have not been studied sufficiently. We investigated arterial stiffness parameters in patients with ST segment elevation (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI). Methods. Ninety-four patients with acute MI (45 STEMI and 49 NSTEMI) were included in the study. Arterial stiffness was assessed noninvasively by using TensioMed Arteriograph. Results. Arterial stiffness parameters were found to be higher in NSTEMI group but did not achieve statistical significance apart from pulse pressure (P = 0.007). There was no significant difference at MACE rates between two groups. Pulse pressure and heart rate were also significantly higher in MACE observed group. Aortic pulse wave velocity (PWV), aortic augmentation index (AI), systolic area index (SAI), heart rate, and pulse pressure were higher; ejection fraction, the return time (RT), diastolic reflex area (DRA), and diastolic area index (DAI) were significantly lower in patients with major cardiovascular events. However, PWV, heart rate, and ejection fraction were independent indicators at development of MACE. Conclusions. Parameters of arterial stiffness and MACE rates were similar in patients with STEMI and NSTEMI in one year followup. The independent prognostic indicator aortic PWV may be an easy and reliable method for determining the risk of future events in patients hospitalized with acute MI.

Detection of aortic plaques by transesophageal echocardiography in patients with ischemic stroke

Twenty‐eight consecutive patients, aged 34–78 years with non‐cardiogenic ischemic stroke were evaluated by transesophageal echocardiography (TEE). All patients were in sinus rhythm. Six of 28 patients (21.4%) displayed protruding masses in the aortic lumen. Five of these masses were located in the ascending aorta and one in the thoracic aorta. Our study suggests that cerebral infarction may also be due to aortic atherosclerotic plaques. Although our findings do not necessarily provide a causative link between atherosclerotic lesions in the aortic lumen and cerebral infarction, they may be an alternative potential source of stroke. TEE is the method of choice in detecting such lesions at the present time.