Hakan Altay

Usefulness of Admission Red Cell Distribution Width as a Predictor of Early Mortality in Patients With Acute Pulmonary Embolism

Red cell distribution width (RDW) is strongly associated with prognosis in cardiopulmonary disorders such as coronary artery disease, acute myocardial infarction, acute and chronic heart failure, and pulmonary hypertension. However, its prognostic significance in acute pulmonary embolism (PE) is unknown. The aim of this study was to investigate the relation between admission RDW and early mortality in patients with acute PE. One hundred sixty-five patients with confirmed acute PE were included. Patients with previous treatment for anemia, malignancy, or chronic liver disease, those with dialysis treatment for chronic renal failure, and those who received erythrocyte suspension for any reason were excluded. A total of 136 consecutive patients with acute PE were evaluated prospectively. According to receiver-operating characteristic curve analysis, the optimal cut-off value of RDW to predict early mortality was >14.6%, with 95.2% sensitivity and 53% specificity. Patients were categorized prospectively as having unchanged (group 1) or increased (group 2) RDW on the basis of a cut-off value of 14.6%. The mean age of patients was 63 ± 15 years. The mean follow-up duration was 11 ± 7 days, and 21 patients died. Among these 21 patients, 1 (1.6%) was in group 1 and 20 (27%) were in group 2 (p <0.001). Increased RDW >14.6% on admission, age, presence of shock, heart rate, oxygen saturation, and creatinine level were found to have prognostic significance in univariate Cox proportional-hazards analysis. Only increased RDW >14.6% on admission (hazard ratio 15.465, p = 0.012) and the presence of shock (hazard ratio 9.354, p <0.001) remained associated with increased risk for acute PE-related early mortality in a multivariate Cox proportional-hazards model. In conclusion, high RDW was associated with worse hemodynamic parameters, and RDW seems to aid in the risk stratification of patients with acute PE.

Relation of Serum Parathyroid Hormone Level to Severity of Heart Failure

Increased parathyroid hormone (PTH) level is associated with all-cause mortality in patients with heart failure (HF). However its role for identifying advanced HF has not been previously studied. We aimed to investigate whether the assessment of serum PTH could enable clinicians to identify patients with advanced HF. One hundred fifty consecutive patients who visited our outpatient clinic with systolic HF were enrolled in the present study. Serum levels of PTH and brain natriuretic peptide (BNP) were measured across all New York Heart Association functional classes. Mean levels of PTH were 43 ± 19, 84 ± 56, 121 ± 47, and 161 ± 60 pg/ml in New York Heart Association functional classes I, II, III, and IV, respectively (p <0.001). In univariate analysis, body mass index, disease duration, PTH, BNP and hemoglobin levels, creatinine clearance, heart rate, systolic blood pressure, left ventricular ejection fraction, left ventricular diastolic diameter, left atrial size, presence of atrial fibrillation, and diuretic usage were found to be predictors of advanced HF. In multivariate logistic regression analysis, PTH level (hazard ratio 1.032, 95% confidence interval 1.003 to 1.062, p = 0.003) and body mass index (hazard ratio 0.542, 95% confidence interval 0.273 to 1.075, p = 0.079) were associated with advanced HF. Furthermore, serum PTH levels were correlated with BNP level and left ventricular ejection fraction (p <0.001 for the 2 comparisons). In receiver operator characteristics curve analysis, the optimal cut-off value of PTH to predict advanced HF was >96.4 pg/ml, with 93.3% sensitivity and 64.2% specificity. In conclusion, measurement of serum PTH could provide complementary information and a simple biomarker strategy to categorize patients with advanced HF based on increased PTH levels, allowing rapid risk stratification in these patients.

Metabolic syndrome is associated with extension of coronary artery disease in patients with non-ST segment elevation acute coronary syndromes.

BackgroundMetabolic syndrome (MS) comprises a group of factors that are associated with increased risk for cardiovascular events. Acute coronary syndromes account for the most important part of cardiovascular events with considerable morbidity and mortality. We aimed to investigate the association of MS with extension of coronary artery disease in patients presenting with non-ST segment elevation (NSTE) acute coronary syndromes (ACS). MethodsThree hundred and six consecutive patients (220 men, 86 women patients) with the diagnosis of NSTE ACS, who were hospitalized within the first 24 h of their chest pain in the coronary care unit, were prospectively enrolled into our study. Patients with elevation of troponins (T or I) were classified as NSTE myocardial infarction (MI) and otherwise as unstable angina pectoris (USAP). Components of MS were noted as previously identified. Coronary angiograms were evaluated by two authors, who were blinded to the study plan and each other, via Sullivans method. ResultsMS was noted in 49% of all patients, and was significantly more common in women than in men (62.8 versus 43.6%, P=0.003). The mean total stenosis score of patients with MS was significantly higher than for those without MS (16±6 versus 12±5, P<0.001), and the mean extension score of patients with MS was significantly higher than for those without MS (63±29 versus 44±26, P<0.001). The presence of MS together with some clinical factors and poor total cholesterol/high-density lipoprotein cholesterol ratio, hypertension and diabetes mellitus, was found to be independently predictive of extension of coronary artery disease (CAD) in a group of patients presenting with NSTE ACS. ConclusionsMS is independently associated with CAD extension, and hence, might account for poor cardiovascular outcomes through CAD extension in patients with NSTE ACS.

Aortic pulse pressure and aortic pulsatility are associated with angiographic coronary artery disease in women

Background. Studies indicated that both aortic pulse pressure (PP) and aortic pulsatility are independently associated with angiographic coronary artery disease (CAD). However, most of these studies included a majority of male subjects, and women were underrepresented. Objective. We investigated the relation of aortic PP and aortic pulsatility derived from invasively measured ascending aortic pressure waveform and presence of angiographic CAD in women undergoing diagnostic coronary angiography. Methods and results. From September 2003 to April 2004, 262 unselected female subjects undergoing first cardiac catheterization were consecutively included in the study. Systolic, diastolic and mean pressure waveforms of the ascending aorta were measured during cardiac catheterization with a fluid‐filled system. Aortic pulsatility was estimated as the ratio of aortic PP to mean pressure. Angiographic CAD was detected in 175 (67%) patients. In multiple‐adjusted logistic regression, both aortic PP and aortic pulsatility were significantly associated with the presence of CAD (for a 10‐mmHg increase in PP: odds ratio [OR] = 1.3, 95% confidence interval [CI] = 1.1–1.76; for a 0.1 increase in aortic pulsatility: OR = 1.8, 95% CI = 1.3–2.4). When patients were divided into tertiles according to the level of aortic pulsatility, it was noted that multiple‐adjusted OR of presence CAD was 2.2 (95% CI = 1.1–4.4) for the middle tertile of the aortic pulsatility level and 5.9 (95% CI = 2.7–12.8) for the highest tertile of the aortic pulsatility level compared with the lowest tertile. Conclusion. In female subjects referred to coronary angiography, ascending aorta PP and aortic pulsatility are significantly associated with the presence of angiographic CAD and these associations are independent of age and other cardiovascular risk factors.

Interpretation of Electrocardiogram Images Sent Through the Mobile Phone Multimedia Messaging Service

OBJECTIVE In this study, the diagnostic accuracy of interpretations of electrocardiogram (ECG) images taken by a mobile phone and sent as multimedia message was investigated. MATERIALS AND METHODS The ECGs of 305 patients who were admitted to the emergency department with cardiac complaints were photographed with the camera of a Nokia (Espoo, Finland) N93 mobile phone. The images were sent via a multimedia messaging system to an identical mobile phone carried by a cardiologist and were interpreted on the screen of that mobile phone. Another cardiologist and an emergency physician interpreted ECG paper printouts separately. The findings of the core laboratory were used as the gold standard. The interpretation errors were scaled from 1 to 4 with respect to the significance of findings. RESULTS The total ratio of Grade 4 errors, which consisted of significant errors, did not show any significant difference (p=0.76) between the interpretations by the emergency medicine specialist and the cardiologist who interpreted the ECGs on the mobile phone; the cardiologist who interpreted the ECG paper printouts made significantly fewer mistakes than the other two specialists (p=0.025 and p=0.023, respectively). The separate assessment of the findings showed that in the diagnostic process of ST-segment elevation, depression, and supraventricular tachycardia, the consistency of the interpretations (κ=0.81, κ=0.81, and κ=1.0, respectively) made on the mobile phone screen was slightly better than that of the emergency medicine specialist (κ=0.73, κ=0.77, and κ=0.80, respectively) and was similar to that of the cardiologist (κ=0.91, κ=0.91, and κ=1.0, respectively) who interpreted ECG paper printouts. CONCLUSIONS Our findings suggest that sending the ECG images via a multimedia message service may be a practical and inexpensive telecardiology procedure.

Left and Right Atrial Myocardial Deformation Properties in Patients with an Atrial Septal Defect

Background: Atrial septal defect (ASD) is a common form of congenital heart defect in adults, which affects all cardiac chambers. Atrial myocardial function in patients with ASD has not yet been clearly elucidated. The aim of this study was to investigate atrial myocardial deformation properties in patients with ASDs. Methods: The study involved 24 patients with a secundum type ASD, and 22 healthy subjects. Color Doppler myocardial imaging was used to measure left and right atrial myocardial systolic strain and strain rate values, together with peak systolic velocity, early velocity, and late diastolic velocity. Results: There was no significant difference between the two groups with regard to age, gender, body mass index, heart rate, blood pressure, left atrial diameter, and ventricular function. The peak systolic atrial myocardial strain and strain rate values in each of the atrial walls studied were lower in the ASD group compared to those of the control group, but the difference reached statistical significance only in the case of the right atrial wall (right atrial strain: 48.0 ± 32.7% vs 100.2 ± 46.6%, P = 0.006; right atrial strain rate: 2.6 ± 1.2/sec vs 3.8 ± 1.2/sec, P = 0.024). Conclusion: The left to right cardiac shunt that results from ASD leads to a reduction in the right atrial myocardial longitudinal lengthening that occurs during ventricular ejection. These findings demonstrate that the reservoir function of the atrium is impaired and atrial stiffness increases in patients with ASDs.

Parathyroid hormone and heart failure: novel biomarker strategy.

Heart failure (HF) is a clinical syndrome featuring cardiac pump failure along with signs and symptoms arising from salt and water retention mediated by activated renin-angiotensin-aldosterone system (RAAS). In addition to this cardiorenal perspective, HF is accompanied by a systemic illness, especially in advanced stages characterized by oxidative stress in various tissues, causing damage to soft tissue and bone. Secondary hyperparathyroidism (SHPT) which is also considered to contribute this systemic illness is therefore prominent in advanced HF. SHPT in HF occurs as a result of RAAS activation, prominent hyperaldosteronism, loop diuretic usage and decreased calcitriol level, all of which results in calcium excretion. We review the evidence that high parathyroid hormone (PTH) is associated with advanced HF, as well as evidence that its associated with HF with preserved ejection fraction (HFPEF).

Comparison of fibrinolytic versus surgical therapy in the treatment of obstructive prosthetic valve thrombosis: a single-center experience.

OBJECTIVE Prosthetic heart valve thrombosis (PVT) is a rare but severe cardiac condition. There are only a few data regarding comparison of the fibrinolytic and surgical approaches for the treatment of PVT. In this study, we compared the results of fibrinolytic therapy versus surgery in patients who presented to our institution with a diagnosis of obstructive-type PVT. METHODS From January 2001 to August 2008 in our institution, 33 patients who met clinical and echocardiographic criteria for obstructive-type PVT were included in the study. Fifteen of these patients underwent fibrinolytic treatment with streptokinase, which consisted of an initial bolus of 250,000 U followed by 100,000 U/h. Eighteen patients were treated with surgery. RESULTS The 2 groups had similar baseline characteristics, including New York Heart Association functional status, types and positions of prosthetic valves, international normalized ratio values, and presentation symptoms. Full hemodynamic success was achieved in 12 patients who underwent fibrinolytic therapy and in 15 patients in the surgery group. The mean (±SD) streptokinase infusion time was 17.8 ± 11.1 hours. Two major hemorrhages and 2 cases of systemic embolism were observed in the fibrinolytic group. The 2 groups did not differ with respect to mortality rate (P = .79). The duration of hospitalization was longer in the fibrinolytic group than in the surgery group (10.7 ± 6.6 days versus 6.9 ± 6.7 days, P = .045). CONCLUSIONS Although fibrinolytic therapy is generally recommended for the treatment of PVT for specific patient groups, our results suggest that it may be as efficacious and safe as surgery, depending on patient selection.

Hemodynamic effects of left upper extremity arteriovenous fistula on ipsilateral internal mammary coronary artery bypass graft.

OBJECTIVE Arteriovenous fistula (AVF) in patients undergoing hemodialysis (HD) may cause coronary left internal mammary artery (IMA) steal. This phenomenon was demonstrated by few prospective studies with limited number of patients and case reports. We aimed to demonstrate with a relatively larger patient population that the AVF may cause ipsilateral IMA steal. METHODS We included 22 prospective patients undergoing HD who had left IMA to left anterior descending artery graft and left upper limb AVF. Right IMA was taken as control. Flows were assessed by using color Doppler ultrasonography. RESULTS The mean age was 57.8 ± 9 years. Statistically nonsignificant increases in AVF flow and decreases in left IMA flow were observed during HD compared with pre-HD. Moreover, fistula localization did not affect median left IMA flows (for peak systolic velocity [PSV] 43.7 versus 70 cm/s, respectively; p = 0.7, and for end diastolic velocity [EDV] 3.4 versus 6.5 cm/s, respectively; p = 0.7). We have not detected significant difference in left IMA flows during HD (median values of PSV 58.4 versus 68.4 cm/s, respectively; p = 0.1, and EDV 6.4 versus 4.4 cm/s, respectively; p = 0.08). Only three patients experienced dialysis-induced reduction of ipsilateral IMA flow that was accompanied by evidence of hypokinesia of the anterior left ventricular wall without clinical angina. CONCLUSIONS Hemodynamically affected left IMA flow by ipsilateral upper extremity AVF may cause steal phenomenon. Hemodynamic differences between left and right IMAs in patients undergoing HD via left wrist and brachial fistulae are limited.

Usefulness of parathyroid hormone as a predictor of heart failure with preserved ejection fraction

Objective: To investigate the relation between parathyroid hormone (PTH) and heart failure with preserved ejection fraction (HF-PEF) in outpatients. Methods: One hundred consecutive patients who had preserved left ventricular (LV) ejection fraction and heart failure (HF) symptoms, were enrolled. Echocardiography, assessing the diastolic functions was performed. Blood samples were collected for intact PTH and brain natriuretic peptide (BNP). Results: Significant correlations between PTH level and predictors of advanced HF-PEF were found (p < 0.05). PTH level and left atrium diameter were found to be independent predictors of DHF. Conclusion: Measurement of serum PTH provides complementary information for the diagnosis and prognosis of HF-PEF.