Hakan Sarlak

The Comparative Effects of Valsartan and Amlodipine on vWf Levels and N/L Ratio in Patients with Newly Diagnosed Hypertension

High levels of circulating Von Willebrand factor (vWf) and increased neutrophil to lymphocyte (N/L) ratio may reflect vascular inflammation in hypertensive patients. In present study, we aimed to investigate the effects of valsartan as an angiotensin II receptor antagonist and amlodipine as a calcium channel blocker on the vWf levels and N/L ratio in patients with essential hypertension. Patients were randomized to one of the following intervention protocols: calcium channel blocker (amlodipine, 5–10 mg/day) as group A (n = 20 mean age = 51.85 ± 11.32 y) and angiotensine II receptor blocker (valsartan, 80–320 mg/day) as group B (n = 26 mean age = 49.12 ± 14.12 y). Endothelial dysfunction and vascular inflammation were evaluated with vWf levels and N/L ratio in hypertensive patients before treatment and after treatment in the 12th week. No statistically significant differences were found among the groups in terms of age, sex, and body mass index (BMI). There was a significant decrease in vWf levels (P < .001) and N/L ratio after treatment (P = .04, P < .001, respectively) in both the groups. Von Willebrand factor levels and N/L ratio are very important markers having a role in vascular inflammation and antihypertensive treatment with amlodipine and valsartan may improve cardiovascular outcomes by decreasing these biomarkers.

Aortic Arterial Stiffness is a Moderate Predictor of Cardiovascular Disease in Patients With Psoriasis Vulgaris

Psoriasis is associated with an increased risk of atherosclerosis. Endothelial dysfunction is the critical early step in the process of atherogenesis, and it is commonly investigated by measuring arterial stiffness. We aimed to investigate the relationship between arterial stiffness and high-sensitivity C-reactive protein (hsCRP) in patients with psoriasis. A total of 32 patients with psoriasis and 35 patients with other skin diseases were included in the study. The hsCRP levels and arterial stiffness measurements were compared. Arterial stiffness was significantly different between the 2 groups (P = .01). Arterial stiffness was not associated with the duration of the disease or the disease activity (P = .34 and .64, respectively). In patients with psoriasis, arterial stiffness correlated positively with age, sex, body mass index, diastolic blood pressure, and hsCRP level (P < .05). These findings provide further evidence of a link between inflammation, premature atherosclerosis, and psoriasis.

Subclinical peripheral arterial disease and ankle-brachial index.

We read the article ‘‘Relation Between Aortic Valve Sclerosis (AVS) and Ankle-Brachial Index (ABI) in Participants Clinically Free of Atherosclerotic Vascular Disease’’ by Korkmaz et al with interest. They investigated the relation between aortic valve sclerosis (AVS) and peripheral arterial disease (PAD) to identify which risk factors are shared and to what extent. They found decreased ankle-brachial ındex (ABI) values in asymptomatic participants with AVS. They also detected a higher prevalence of AVS in patients with asymptomatic PAD. Ankle-brachial ındex is a valuable diagnostic tool for PAD. The 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. Although if the ABI is either <0.9 or >1.4 PAD is predicted to be present, previous studies demonstrated an ABI <0.9 is not only a marker of unrecognized PAD but also a predictor of generalized atherosclerosis. For this reason, the results might be different, if Korkmaz et al had taken the cutoff value of ABI as <0.9 or >1.4 in their study. The early diagnosis of PAD and the initiation of conservative measures are related not only with a reduction in disease progression but also with numerous additional beneficial actions. For example, PAD is associated with the metabolic syndrome which requires treatment in its own right. 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 ABI paremeters. Because of the difference between the 2 groups in medications such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, b-blockers, aspirin, it would be better if the authors carried out a multivariate regression analysis and adjusted for other related factors (such as hypertension, diabetes mellitus, smoking, hypercholesterolemia, and medications). 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, ABI is the easiest, low-cost, reliable, noninvasive, and most widely available parameter among the tested tools and could help detect the presence of subclinical atherosclerosis. Besides the ABI, several other markers/tests such as Creactive protein functional photoplethysmograph technology using a noninvasive automated device may reflect the presence of PAD. Both have the advantage that, unlike the ABI, they are less operator dependent. Future studies should evaluate the prognostic significance of these variables in patients with PAD as well as their ability to identify unrecognized PAD. We believe that these findings will provide useful information about the measurement of ABI and PAD management.

Peripheral Arterial Disease Assessment With Photoplethysmography and Continuous-Wave Doppler Ultrasound in Addition to Ankle-Brachial Index May Loss Time and Funds

We read the article ‘‘Photoplethysmography and ContinuousWave Doppler Ultrasound as a Complementary Test to Ankle Brachial Index in Detection of Stenotic Peripheral Arterial Disease’’ by Du Hyun Ro with interest. They concluded that ankle-brachial index (ABI) showed a significantly decreased sensitivity in detection of anatomically stenotic peripheral arterial disease (PAD), especially in stenosis below trifurcation level and both photoplethysmography (PPG) and continuouswave Doppler ultrasound (CWD) were complementary to ABI in these patients. Measurement of ABI manually by Doppler is a well-established method to screen for PAD and to predict the cardiovascular risk of patients. In this study, measuring PPG and CWD in addition to ABI measurement in patients with probable PAD was suggested as the ABI has a sensitivity of 69.3% and a specificity of 99.6% and it may miss a diagnosis of PAD. But in real life, a measurement of ABI as well as these additional methods may consume more time and lead to higher costs. Further studies are needed to answer these questions. A second challenge in the study is that the authors discussed ABI measurements but we do not know the real-time aortic or brachial blood pressure of these patients. It would be better if they provided enough data and the blood pressure measurements were standardized.

Epicardial adipose tissue measurement: inexpensive, easy accessible and rapid practical method.

We have read the article “Epicardial adipose tissue (EAT) is independently associated with increased left ventricular mass in untreated hypertensive (UHT) patients: an observational study” written by Erdoğan et al. (1) with a great interest. The authors aimed to evaluate the relationship between EAT and left ventricular hypertrophy (LVH) in patients with UHT. They concluded that EAT was related to increased LVM independent of body mass index (BMI), waist circumference, weight, systolic and diastolic blood pressure and other risk parameters, in patients with UHT. Determination of increased EAT by echocardiography may have an additional value as an indicator of cardiovascular risk and total visceral adipose tissue. Thanks to the authors for their contribution of the present study, which is successfully designed and documented. Cardiovascular diseases are the most important causes of mortality and morbidity in developed countries worldwide. It is widely recognized that accumulation of EAT is strongly related to the development of coronary artery disease (CAD). EAT amount may contribute to systemic inflammation beyond traditional cardiovascular risks and body fat composition. EAT measured by echocardiography has been known to be associated with metabolic syndrome (2). Additionally, echocardiography-based EAT measurement was related to several metabolic abnormalities and independently associated fatty liver disease (3). On the other hand, in kidney disease patients, EAT was positively correlated with atherosclerosis and the presence of coronary artery calcification (4). In addition, the duration of hypertension (HT) may be different in these patients. We think that the results of the study would be stronger, if the authors had mentioned these factors including the duration of HT, liver and kidney function tests. EAT can also be affected by the atherosclerotic risk factors such as alcohol consumption, hypothyroidism, impaired glucose tolerance and higher inflammatory status (5) such as an inflammatory disease, cardiac syndrome X and infection (6). In this point of view, in the present study, the authors did not mention some of these possible contributing factors. It would be better, if the authors gave information about these factors. EAT measurement with echocardiography has several advantages, including its inexpensive, easy accessibility, rapid applicability and good reproducibility. EAT has a 3-dimensional distribution and two-dimensional echocardiography cannot give adequate window of all cardiac segments especially in obese subjects and is highly dependent on acoustic windows. In this point of view, it would be better to give interobserver and intra-observer variability for EAT measurement in the current study (7). Finally, EAT itself without other inflammatory markers may not provide information to clinicians about the systemic inflammation. Therefore, we think that it should be evaluated together with other serum inflammatory markers. We believe that these findings will evaluate further studies about EAT on cardiovascular risk factors.

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.

Response to Red Blood Cell Distribution Width Is a Predictor of Readmission in Cardiac Patients

Ephrem G. Clin Cardiol. 2013. doi: 10.1002/clc.22116

Fluid necessity should be followed by central venous pressure

We intentionally read the article “Fluid balance in sepsis and septic shock as a determining factor of mortality” written by Sirvent et al [1] with interest. They concluded that a positive fluid balance in the first 4 days was associated with higher mortality in severe sepsis and patients with septic shock [1]. There is a global tissue hypoxia in severe sepsis and septic shock, which may proceed to multiorgan failure and death [2]. Too little fluid may result in tissue hypoperfusion and worsen organ dysfunction [3]. Intravenous fluids, source control, vasopressors, inotropic agents, and mechanical ventilation are a key component in the early management of septic shock [3] and used to a balance in normalized values for mixed venous oxygen saturation, arterial lactate concentration, base deficit, and pH [2]. It is necessary that early central venous catheter is placed and a central venous pressure measured as an indicator of volume responsiveness [4]. The major elements of early goal-directed therapy include fluid resuscitation to achive a central venous pressure of 8 to 12 cm of water and to maintain the central venous oxygen saturation higher than 70% [5]. We think that fluid necessity should be followed by central venous pressure. Positive fluid balance is a result of low urine output because of tissue hypoperfusion and renal failure. There is a positive correlation between mortality and renal failure induced by tissue hypoperfusion. For this reason, creatinine and lactate levels should be monitored closely initially and after.

Anaemia is a predictor of mortality in patients undergoing aortic valve surgery

We read the article ‘Preoperative anaemia is a risk factor for mortality and morbidity following aortic valve surgery (AVS)’ by Elmistekawy et al. [1] with interest. They aimed to investigate the incidence of preoperative anaemia in patients undergoing nonemergency AVS and its association with postoperative outcomes. They concluded that preoperative anaemia is a common finding in patients undergoing AVS and is an important and potentially modifiable risk factor for postoperative morbidity and mortality. We believe that these findings will pave the way for further studies about the relationships between preoperative anaemia and AVS. Thanks to the authors for their contribution. It is actually believed that patients undergoing heart surgery have a lower margin of safety for tolerance of low haemoglobin (Hg) levels. A significant association between anaemia with adverse outcomes (death, stroke and renal impairment) in patients undergoing cardiac and non-cardiac surgery has been demonstrated in previous studies [2]. Blood transfusion is dangerous with regard to in-hospital mortality, morbidity and long-term survival. Blood transfusion is frequently used as a volume expander while simultaneously increasing the haematocrit. Transfusions have been independently associated with increased mortality after cardiac surgery. Transfusion is also dose-dependent risk factor for early mortality after revascularization. Blood transfusions have been linked to postoperative renal dysfunction, pneumonia, wound infections, severe sepsis and hospital mortality [3]. Based on this point of view, because anaemia and need for blood transfusions lead to very significant adverse effects after cardiopulmonary bypass surgery, it is necessary to research the effective methods of anaemia correction to reduce the need for blood transfusions. Nowadays, although anaemia is a predictor of postoperative complications and is a risk factor for mortality in patients after cardiac surgery treatment, red distribution width (RDW) is known as an independent early marker of Hg evolution and independently identified risk of new onset anaemia, providing predictive information for haematological abnormalities beyond Hg concentrations and other known risk factors. RDW has recently been identified as an independent predictor of all-cause long-term mortality in patients with coronary artery disease [4]. So, if the authors had mentioned RDW, the results of the study might be different. Reduced glomerular filtration rate (GFR) may also be associated with adverse outcomes in patients with cardiovascular disease. In previous study, preoperative GFR was predictive of all-cause mortality, cardiovascular mortality and combined cardiovascular mortality and morbidity. GFR may be useful to identify those patients undergoing cardiovascular surgery with subclinical chronic kidney disease [5]. For this reason, it would be better, if the authors mentioned any of these possible conditions. Finally, it would be better if the authors might define how much time they specified on measuring Hg levels, because it can be associated with haemodilutional anaemia [6]. Following cardiac surgery, some factors including longer hospital stays, increased risk of infection, higher rate of pulmonary complications, prolonged ventilation, stroke, renal failure, atrial fibrillation, myocardial infarction, pneumonia, prolonged ventilation and operation time are associated with increased morbidity and mortality rates in patients undergoing AVS [3]. So, the further studies should evaluated these factors in patients with AVS.

Hyperuricemia may be related to contrast-induced nephropathy after percutaneous coronary intervention

Dear Editor, We have read with great interest the recently published article titled, “The relationship between hyperuricemia and the risk of contrast-induced nephropathy after percutaneous coronary intervention in patients with relatively normal serum creatinine”, by Yong Liu et al. (1). In that well-presented paper, the authors investigated the value of hyperuricemia in predicting the risk of contrast-induced nephropathy (CIN) in patients with relatively normal serum creatinine who are undergoing CIN. They demonstrated that CIN might develop in patients with normal creatinine levels. Hyperuricemia is a significant and independent predictor of CIN after percutaneous coronary intervention (PCI) and results in significantly increased in-hospital mortality and CIN incidence, which requires renal replacement therapy after PCI. Thus, despite having normal baseline creatinine levels, patients with hyperuricemia, an intra-aortic balloon pump, emergent PCI, or older age should receive more comprehensive renal prophylaxis to reduce the occurrence of CIN. CIN has been recognized as a serious complication of PCI and may cause increased morbidity and mortality. CIN is one of the most important reasons for hospital-acquired renal failure and can cause prolonged hospitalization, increased cost and incidence of renal and cardiovascular events, and mortality. Elderly patients have a higher risk of CIN because of decreased renal reserve. In addition, some factors, such as an estimated glomerular filtration rate (eGFR) of 200 mL have been identified as risk factors for CIN after PCI (2). Additionally, alcohol consumption and the arterial blood pressure level before contrast exposure may be associated with CIN. Hypertriglyceridemia, metabolic syndrome, an impaired fasting glucose level, and multivessel disease may also be associated with a higher incidence of CIN (3). Some medications, including renin-angiotensin-aldosterone system medications, may also be related to CIN (4). It would have been interesting for the authors to provide information about these factors in this study. Finally, the authors used the Cockcroft-Gault equation to measure eGFR. The Cockcroft-Gault equation may underestimate eGFR in younger age groups and may overestimate eGFR in older individuals compared with the Modification of Diet in Renal Disease (MDRD) formula (5). Although the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) recently published an equation for eGFR using the same variables (serum creatinine level, age, sex, and race) as the MDRD formula, the CKD-EPI equation more accurately categorized individuals with respect to long-term clinical risk (6). In addition, even mild chronic kidney dysfunction, defined as an eGFR <90 mL/min, and dehydration were risk factors for CIN. For this reason, it may be useful to include the results using the CKD-EPI equation and accounting for mild chronic kidney dysfunction and dehydration as risk factors for CIN.