Fahri Gurkan Yesil

Epicardial adipose tissue should be evaluated with other inflammatory markers in patients with subclinical hypothyroidism.

impaired glucose tolerance and higher inflammatory status such as an inflammatory disease, cardiac syndrome X and infection [8] . In addition, antihypertensive therapy (such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, betablockers), statins and some medications such as used for weight loss and a medical history of drug addiction might affect EAT based on inflammation [9] . It would have been useful, if the authors had mentioned these factors. Several studies have demonstrated that there has been a strong relationship between serum inflammatory markers and subclinical atherosclerosis [10] . So, EAT itself without other inflammatory markers may not provide information to clinicians about systemic inflammation. So, we think that it should be evaluated together with other serum inflammatory markers. We believe that these findings will enlighten further studies about EAT on SH. Dear Editor, We have read the article ‘Epicardial adipose tissue increased in patients with newly diagnosed subclinical hypothyroidism’ with great interest [1] . The authors speculated that epicardial adipose tissue (EAT) might be increased in patients with subclinical hypothyroidism (SH) and it could relate to the development of cardiovascular disease in such patients due to higher levels of EAT in patients with SH than in controls. This may help explain the pathological mechanisms of thyroid dysfunctions related to coronary artery disease. Thanks to the authors for their contribution of the present study, which is successfully designed and documented. The stages for treatment of SH are progression to overt hypothyroidism, poor quality of life related to nonspecific symptoms and suspected association with atherosclerosis. It is not known whether or not SH is related to risk for cardiovascular disease [2] . SH is associated with an increased risk of coronary artery disease events and coronary artery disease mortality in patients with high thyroid-stimulating hormone levels ( ≥ 10 mIU/l) [3] . Cardiovascular diseases are the most important causes of mortality and morbidity in developed countries worldwide [4] . The EAT measured by echocardiography has been known to be associated with metabolic syndrome. Several clinical studies have revealed that there is a correlation between the amount of EAT and coronary atherosclerosis. Additionally, although the relationship between fatty liver disease and EAT has been reported previously [5] , Korkmaz et al. [1] did not mention this relationship between EAT and fatty liver disease. The main cause of morbidity and mortality in kidney disease patients has been established to be cardiovascular disease [6] . On the other hand, in kidney disease patients, EAT was positively correlated with atherosclerosis, arterial stiffness and the presence of coronary artery calcification [7] . We think that the results of the study would be stronger, if the authors had mentioned these factors including liver and kidney function tests. Other atherosclerotic factors that affect EAT that the authors did not mention include alcohol consumption, hypothyroidism, Published online: April 6, 2013

The Relation between Decreased Glomerular Filtration Rate and Nonvalvular Atrial Fibrillation

No abstract available

Only ankle-brachial index may not be an accurate information about the prevalence of peripheral arterial disease.

We read the article ‘‘Peripheral arterial disease is prevalent but underdiagnosed and undertreated in the primary care setting in central Greece’’ by Argyriou et al with interest. They investigated the prevalence of peripheral arterial disease (PAD) and assessed in physician and patient the awareness of the disease as well as the risk factors associated with PAD and the level of its treatment. They demonstrated that the prevalence of PAD, especially asymptomatic PAD, is prominent among participants aged 50 to 70 years. The ankle-brachial index (ABI) is a valuable diagnostic tool for PAD. Measurement of ABI in patients with subclinical PAD allows the timely initiation of preventive measures as well as the recognition of vascular disease in other arterial beds. Previous studies demonstrated that an abnormal ABI is not only a marker of PAD but also a predictor of generalized atherosclerosis. For this reason, the results might be different, if the authors had mentioned cardiovascular risk factors in their study. The early diagnosis of PAD and the initiation of conservative measures are related not only to a reduction in disease progression but also to numerous additional beneficial actions. Aggressive vascular risk factor modification in patients with PAD is associated with a reduction in the risk of vascular events as well as decreased disease progression. Furthermore, some medications such as antihypertensive treatment, aspirin, and statins may influence the ABI parameters. A low ABI has been demonstrated as a marker of decreased renal function over time in a general population of patients, and the presence of concomitant renal dysfunction in patients with PAD is associated with higher morbidity and mortality rates as well as the occurrence of cardiovascular events. It would be useful if the authors provide data about these risk factors and their possible relationship with the ABI. Finally, measurement of ABI manually by Doppler is a well-known method to diagnose PAD. In a previous study, measuring the photoplethysmography and continuous-wave Doppler ultrasound in addition to ABI measurement in patients with a probable PAD was suggested in suspected patients as the ABI has a sensitivity of 69.3% and a specificity of 99.6%, and in this regard it may miss a real diagnosis of PAD. But in real life, the measurement of ABI and the practice of these additional tools may consume more time and lead to higher costs. This may decrease the effectiveness of these methods. Further studies will be needed to reveal the clinical relevance of these additional investigations. Besides the ABI, several other markers or tests such as C-reactive protein, functional photoplethysmography, and using a noninvasive automated device may reflect the presence of PAD. We believe that these findings will provide useful information about the ABI measurements and diagnosis of PAD.

Is It Possible to Prevent Acute Kidney Injury in Patients Who Underwent Contrast Medium

We read with interest the article by Alharazy et al concerning the early diagnosis of acute kidney injury (AKI) after using contrast medium. Contrast-induced nephropathy (CIN) is the third most common cause of AKI in hospitalized patients (11% of the cases). Early diagnosis is vital because prevention is possible. There are new serum markers for the early diagnose of CIN. Among these, Alharazy et al demonstrated that serum neutrophil gelatinase-associated lipocalin was an early biomarker of CIN in patients with chronic kidney disease undergoing coronary catheterization. Renal insufficiency is associated with many diseases including acute myocardial infarction. Because of that, preventive treatments are important. In the study of Alharazy et al, despite preventive measures, the frequency of CIN was 11%, similar to that reported by others. A number of methods have been used to prevent CIN. Alharazy et al administered intravenous normal saline and oral N-acetylcysteine. Among preventive treatments of CIN, alkalinization of urine has an important place. Sodium or potassium citrate is a well-known agent for urine alkalinization, but unfortunately, it may not be commonly used. It has been reported that patients with a urine pH < 6 had a >10-fold higher risk of CIN compared with patients whose urine pH was >6. Gene polymorphisms may play a role in CIN development. Gene polymorphisms of interleukin 10 and tumor necrosis factor-a were found to be associated with CIN development. Alharazy et al demonstrated that patients of Indian ethnicity are predisposed to CIN. We suggest that gene polymorphisms may play a role in this predisposition. Prospective cohort studies should evaluate this potential relationship.

Carotid Intima-Media Thickness: A Novel Inflammatory Marker Which Should Not Be Assessed Alone!

No abstract available

Red cell distribution width may be related to the degree of coronary collateral circulation.

We read the article ‘‘Relation of Coronary Collateral Circulation With Red Cell Distribution Width in Patients With Non-ST Elevation Myocardial Infarction’’ by Tanboga et al with interest. They aimed to investigate the relationship between red cell distribution width (RDW) value and coronary collateral circulation (CCC) in patients with non-ST elevation myocardial infarction (NSTEMI). They concluded that high RDW, high creatine kinase-MB, and absence of preinfarction angina were found to be independent predictors for impaired CCC. We believe that these findings will enlighten further studies about the relationships of coronary collateral (CC) development. Thanks to the authors for their contribution. The CCC is an adaptive response to myocardial ischemia. Well-developed collaterals are associated with reduced mortality in patients with stable coronary artery disease and reduced infarct size in patients with acute myocardial infarction. There are interconnecting vessels between the main arteries, which can prevent ischemia despite coronary artery occlusion in many patients. These interconnections of vessels, which can be visualized and graded by angiography, represent the CCC, an alternative route for the myocardial perfusion. In this study, CCs were scored by visual analyses and were evaluated according to the Rentrop grading system; patients with Rentrop grades 0 and 1 were classified as group 1 (in whom CC development was coded as inadequate), and patients with Rentrop grade 2 and 3 were classified as group 2 (adequate CC development). Then, they compared between these 2 groups. But, in some studies like Refiker et al the patients were classified into impaired CC development (group 1, Rentrop grades 0-1-2) and adequate CC development (group 2, Rentrop grades 3) groups. Duran et al accepted Rentrop grade 0 as absence of CC vessels, and they accepted Rentrop grade 1 as presence of CC vessels. So, what are the criteria for the definition of adequate or inadequate CC development? A subgroup analysis of Rentrop grading system according to each of the 4 groups might affect the results of the study. It would be better if the authors added subgroup analysis according to Rentrop grading system, respectively. The RDW has been recently proposed as an independent predictor of all-cause long-term mortality in patients with NSTEMI 2 and in another study. Sometimes conditions like the differential diagnosis of anemia might affect RDW parameter, and so this parameter might be changed in such an underlying condition. The anemic disease situation may mask the chronic ongoing inflammation. After that, not only RDW but also neutrophil–lymphocyte ratio, gamma-glutamyltransferase, and uric acid are easy methods to assess the CCC in the patients. These might be useful in clinical practice. The RDW itself alone without other inflammatory markers may not give information to clinicians about the inflammatory condition and prognostic indication of the patient. So, we think that it should be evaluated together with other serum inflammatory markers. Finally, it would be better if the authors define how much time they spent in measuring RDW levels, because delayed blood sampling can cause abnormal results in RDW measurements. We think that further studies should be made to enlighten the role of RDW as a prognostic indicator in patients with NSTEMI.

The Importance of Histopathological Findings in Saphenous Vein Grafts

procedures [3] . We already know that many factors can affect these conditions. Such factors are: the coronary anatomy before the bypass procedure, the anatomical features of the graft (e.g. arterial or venous graft and the histopathologic features), comorbid diseases (including diabetes, hyperlipidemia, hypertension, smoking and renal failure [4] ) and the effectiveness of medical treatment. The study showed the presence and degree of luminal narrowing and a weak correlation with the presence or absence of luminal atherosclerotic plaques. In fact, conventional angiography is not comprehensive enough, and may not reveal all the defects of the vascular structure; it is actually a kind of lumenography and is less sensitive in lesions smaller than 40% of the size of the vascular lumen. The authors do partly acknowledge this, saying that although conventional angiography describes the degree of luminal narrowing, it may not completely observe atherosclerotic plaques. Intravascular ultrasonography has facilitated our understanding of atherosclerotic disease, especially atherosclerotic plaques. However, it provides less detail for pathophysiological investigation compared to microscopic evaluation. Histopathological examinations ensure the most accurate clues to a better understanding of human We read the article ‘Histopathologic Insight into Saphenous Vein Bypass Graft Disease’ written by Bikdeli et al. [1] with great interest. The authors investigated the histopathological characteristics of old human vein grafts and assessed the correlation between angiographic and histological findings. They demonstrated that conventional coronary angiography has a moderate correlation with the presence and degree of luminal narrowing and a weak correlation with the presence or absence of luminal atherosclerotic plaques. They suggested that an improved understanding of disease pathophysiology could lead to the development of novel interventions that reduce costly and suboptimal repeat revascularizations. Thank you to these authors for their contribution. Coronary-artery bypass grafting is associated with greater freedom from repeat revascularization for patients with ischemic heart disease [2] . Human aortocoronary grafts may be compromised postoperatively or due to early thrombosis or fibrointimal hyperplasia. The long-term patency rate of vein grafts is approximately 50%, and the main cause of graft failure is atherosclerosis. Graft failure leads to a recurrence of ischemic symptoms and clinical deterioration, mandating costly, riskier and less effective repeat revascularization Received: December 28, 2012 Accepted: December 28, 2012 Published online: March 12, 2013

A novel point for warfarin usage in ACCP Guidelines, 2012 and its importance for quality of anticoagulation. Commentary on the article by Dr. Ciurus et al. (Kardiochir Torakochir Pol 2015; 12 (4): 334-340)

We have read with great interest the article about the factors affecting the quality of anticoagulation with warfarin by Ciurus et al. [1]. The authors implicate the importance of predictors of controlling the anticoagulation. They aim to assess the quality of anticoagulant therapy in patients on warfarin and evaluate the factors affecting its deterioration. We thank the authors for their well-designed study. Regarding the current guidelines concerning anticoagulant therapy, we detected some contradictory and overlooked points that should be highlighted. We want to make some contributions to the report by Ciurus et al. [1] about the warfarin usage introduction update and education change according to current guidelines. Despite the presentation of new anticoagulants, vitamin K antagonists (VKA) still maintain their importance in clinical administration [2]. Unfortunately, this wide use of VKA is still associated with a wide spectrum of complications. Particular concerns have been raised regarding prevention of these complications. As one of them, the Ciurus et al. emphasized that maximizing the time in the optimum therapeutic range has great importance for avoiding adverse clinical outcomes [1]. To attain this goal, controlling the patient-specific factors such as adherence to the therapeutic plan, appropriate dosing, and reliable international normalized ratio (INR) control are very important. Among such patient-related factors, the feeding habit of the patients is a special issue. Many doctors and patients remember the wide VKA interaction food list containing dietary vitamin K. It has been a frequent practice to limit or alter dietary habits of the patients according to those food lists. But this clinical advice has been changed by the American College of Chest Physicians (ACCP) Evidence-Based Clinical Practice Guidelines, 2012 [3]. It is suggested in the abovementioned document that limitations of diet deteriorate the therapeutic INR levels. Because most people have long-lasting dietary habits, which are very difficult to change, attempts to change any dietary habit may result in uncontrolled alterations of oral vitamin K intake, resulting in difficulties sustaining the therapeutic INR levels. The ACCP guidelines recommend that “A consistent intake of vitamin K-containing foods is advisable, but neither specific restrictions nor additions seem necessary in patients with stable anticoagulant control. Patients should be informed of possible changes in INR, in particular in response to the use of dietary supplements or herbs, or alcohol used chronically or ingested in large quantities.” The authors reported that, “The participants were informed about the diet limitations required in order to improve the effectiveness of the anticoagulant therapy.” Although this suggestion is valid for attaining a therapeutic level, it is very difficult to maintain this level in therapeutic doses. That is why we think the ACCP guidelines made a modification on warfarin use in 2012, which we cannot see in the previous guidelines from 2008 [4]. We also agree with the suggestion that the patient should be informed about the food and drug interactions but no suggestion should be made on limiting dietary intake, in order to maintain therapeutic INR levels.

Left atrial appendage mass: is it always a thrombus?

Myxoma is the most common benign tumor of the heart, but it is very rare for it to originate from the left atrial appendage. Distinguishing between a mass, a thrombus, and a tumor in the body of the left atrium with preoperative transthoracic or transesophageal echocardiography is very difficult, even more so in patients with mitral valve disease and chronic atrial fibrillation. A 50-year-old male patient was admitted for surgery with the diagnosis of mitral stenosis and chronic atrial fibrillation. Transesophageal echocardiography demonstrated a mass attached to the wall of the left atrial appendage. Histopathological examination of the mass showed an image compatible with a myxoma. We hereby describe a case of a left atrial appendage myxoma mimicking a left atrial appendage thrombus.

Contents Vol. 124, 2013

No abstract available