Hasan Korkmaz

Evaluation of Endothelial Dysfunction: Flow-Mediated Dilation

By the time the clinical findings of atherosclerotic disease appear, involvement is usually at an advanced stage and procedures after this stage are usually palliative or aimed at secondary protection. On the other hand, prevention can be achieved by the detection and treatment of endothelial dysfunction, which is one of the most important changes in the early subclinical stage of atherosclerotic disease. When the systemic involvement of endothelial dysfunction is taken into consideration, checking from the peripheral arteries with noninvasive methods gives one-to-one correct information. Currently, endothelial dysfunction can be detected using simple, inexpensive, and noninterventional methods. Particularly, easily accessible localization of the brachial artery is ideal for the evaluation of endothelial dysfunction. Flow-mediated dilation method (FMD; endothelial-dependent vasodilation), which can be carried out noninvasively with ultrasonography on the brachial artery, is a frequently used method for the assessment of endothelial dysfunction. A sphygmomanometer is placed on the forearm to create a flow stimulation in the brachial artery. The sphygmomanometer is inflated until the systolic pressure is above 50 mm Hg, thus stopping the antegrade blood flow and creating ischemia. Consequently, vasodilation occurs at the resistance arteries distal to where the flow is blocked. When the sphygmomanometer is deflated, a reactive hyperemia occurs in the brachial artery. The % difference between the diameter measured after reactive hyperemia and the basal diameter is taken as FMD. The effects of the treatments on endothelial dysfunction can be monitored with this method. Studies have shown that angiotensin-converting enzyme (ACE) inhibitors, angiotensin 1 (AT1) receptor blockers, latest-generation beta blockers such as nebivolol and carvediol, statins, estrogen treatment, diet, and exercise increase FMD. Before this method becomes a part of routine clinical evaluation of cardiovascular disease (CVD) risk, measurement technique and FMD values need to be standardized.

Early Effects of Treatment with Nebivolol and Quinapril on Endothelial Function in Patients with Hypertension

The objective of the present study was to compare the early effects of treatment with nebivolol and quinapril on the endothelial function in hypertensive patients. A total of 54 hypertensive patients was enrolled in the present study. One of the groups (n = 27) received quinapril 20 mg/day, and the other group (n = 27) received nebivolol 5 mg/day for a period of 4 weeks. The endothelial dysfunction was assessed using FMD (flow-mediated vasodilation) of the brachial arteries. The baseline characteristics of both groups were similar in age, gender, left venticular ejection fraction, left ventricular mass index, and body mass index. No significant difference was also found between the groups in the distribution of atherosclerotic risk factors as well as other echocardiographic, demographic, and biochemical measurements. Although the reduction of diastolic blood pressure was more pronounced in the nebivolol group after a 4-week treatment, the change in the systolic blood pressure was found to be similar in both treatment arms. Although a statistically nonsignificant increase was observed in flow-mediated vasodilation in the quinapril group (4.77% +/- 3.92%, 5.60% +/- 6.18%; p = .587), the increase in the post-treatment FMD was statistically significant in the nebivolol group (3.78% +/- 4.25%, 8.56% +/- 6.39%; p = .002). A significant change was observed in the resistive index value following flow-mediated vasodilation for both groups after treatment (p = .043; p = .027), whereas the change in the value of flow volume was significant only in the nebivolol group (p = .019).

The level of hs-CRP in coronary artery ectasia and its response to statin and angiotensin-converting enzyme inhibitor treatment.

Background/Aim. Coronary artery ectasia (CAE) was thought of as a variant of atherosclerosis. C-reactive protein (CRP) which is among the most sensitive markers of systemic inflammation, and elevation of systemic and local levels of this inflammatory marker which has been associated with an increased risk for cardiovascular disease in the obstructive coronary artery disease (O-CAD) are well known, but little was known in CAE. The anti-inflammatory effects of statins and the effect of angiotensin-converting enzyme (ACE) inhibitors on endothelial dysfunction are well established in atherosclerosis. The aim of the present study was to investigate CRP level and its response to statin and ACE inhibitor treatment in CAE. Materials and method. We measured serum hs-CRP level in 40 CAE (26 males, mean age: 56.32 ± 9 years) and 41 O-CAD (34 males, mean age: 57.19 ± 10 years) patients referred for elective coronary angiography at baseline and after 3-month statin and ACE inhibitor treatment. Results. Plasma hs-CRP levels were significantly higher in CAE group than O-CAD group at baseline (2.68 ± 66 mg/L versus 1, 64 ± 64, resp., P < .0001). Plasma hs-CRP levels significantly decreased from baseline 3 months later in the CE (from 2.68±0.66 mg/L to 1.2±0.53 mg/L, P < .0001) as well as in the O-CAD group (from 1.64±0.64 mg/L to 1.01±0.56 mg/L, P < .001). Conclusion. We think that hs-CRP measurement may be a good prognostic value in CAE patients as in stenotic ones. Further placebo-controlled studies are needed to evaluate the clinical significance of this decrease in hs-CRP.

Association of Mitral Annulus Calcification with High-Sensitivity C-Reactive Protein, Which Is a Marker of Inflammation

Objectives. There are limited clinical data revealing the relationship between mitral annular calcification (MAC) and systemic inflammation. The goal of the present study was to compare high-sensitivity C-reactive protein (hs-CRP) levels in patients with and without MAC and investigate the relationship between MAC and hs-CRP. Methods. One hundred patients with MAC who underwent transthoracic echocardiography (TTE) and 100 age-matched controls without MAC who underwent TTE were included in our study. Hs-CRP levels were compared between groups. Results. Prevalence of female gender, hypertension, and coronary artery disease were significantly higher in the MAC group than in the control group (64% versus 45%, P = 0.007, 42% versus 28%, P = 0.03 and 37% versus 18%, P = 0.003, resp.). On multivariate analysis, age, gender, and coronary artery disease were the only independent predictors of MAC. The levels of hs-CRP were higher in the MAC group than in the control group (2.02 ± 0.35 versus 1.43 ± 0.47 mg/dl, P < 0.001). This increase in hs-CRP levels in the MAC group persisted in patients without hypertension, coronary artery disease, and in male patients when compared to the control group. Conclusions. Our study demonstrated that hs-CRP, which is a sensitive marker of systemic inflammation, increased in patients with MAC.

The Comparison of Cardiac Biomarkers Positivities in Hemodialysis Patients without Acute Coronary Syndrome

Aim: We aimed to compare heart-type fatty acid-binding proteins (H-FAB) and other cardiac biomarkers to determine the most reliable cardiac marker in hemodialysis (HD) patients without acute coronary syndrome (ACS). Materials and methods: Sixty HD patients without ACS were included the study. Blood samples were taken before HD session for measurement of H-FAB, troponin I, troponin T, creatine kinase-MB (CK-MB) isoforms. Results: Mean age of patients was 55 ± 15 years. Males were 55%. Mean serum level of blood urea nitrogen was 75 ± 15 mg/dL, mean serum level of creatinine was 8.3 ± 2.5 mg/dL, mean serum level of hematocrit was 33 ± 5%, mean ejection fraction was 54 ± 9%, and mean left ventricular mass index (LVMI) was 136 ± 54 g/m2. H-FAB was positive in 32%, troponin T in 20%, troponin I in 12%, and CK-MB in 5% of all patients. Three or four of all parameters were not positive together in any patient. While 5% of patients had positive troponin T with H-FAB, 3% of patients had positive troponin T with troponin I and 2% of patients had positive troponin I with H-FAB. Conclusion: Our study found that CK-MB had the lowest positivity in the HD patients without ACS. H-FAB had the highest rate of positivity in all markers. If only one marker is assessed it should be CK-MB. But using two parameters in HD patients in ACS diagnosis increases the reliability of diagnosis. If we use two biomarkers it should be CK-MB and troponin I.

The Importance of Cardiac Biomarkers on Remodelling After Myocardial Infarction

Background The purpose of this study is to evaluate the importance of tenascin-C ( TNC), N-terminal pro brain natriuretic peptide (NT-proBNP) and C-reactive protein (CRP) on LV remodelling after myocardial infarction (MI). Methods Fifty-seven stable patients with subacute anterior MI who had total or subtotal occlusion in the infarct-related left anterior desending artery in coronary angiography were enrolled the study. 18 of patients who had total occlusion received only medical theraphy, 19 of patients who had total occlusion received successful PCI+ medical theraphy and 20 of patients who had subtotal occlusion received successful PCI+ medical theraphy. Left ventricular volumes and ejection fractions (EF) were measured with echocardiography. Serum TNC, NT-proBNP and CRP levels were measured at admission and a month after treatment. Results There was significant increase in LV end-diastolic volume (LVEDV) and LV end-systolic volume (LVESV) baseline to follow-up in total-PCI group. Baseline to follow-up; a borderline significant increase was observed in LVEDV in the total-medical group. No significant difference was seen in LV volumes and EF in the subtotal-PCI group. NT-proBNP, TNC and CRP levels were decreased in all groups. The decrease in NT-proBNP and CRP values were significant in the total-medical and subtotal-PCI group but in the total-PCI group they were not significant. The decrease of TNC was significant in all groups but the lowest decrease was seen in the total-PCI group. Conclusion TNC, NT-proBNP and CRP reflect LV remodelling in accordance with echocardiography after MI. Keywords Tenascin-C; NT-pro BNP; CRP; Remodelling; Myocardial infarction

[The relation of intima-media thickness with endothelial function and left ventricular mass index].

OBJECTIVE We aimed to investigate the relation of brachial artery intima-media thickness (IMT) with endothelial function and left ventricular mass (LVM). METHODS Fifty-four stage I-II hypertensive patients according to JNC VII who were not taking any medication and 27 age and sex-matched healthy controls were included to this cross-sectional observational study. IMT was measured by the same radiologist who was unaware of the patients clinical status by using high resolution ultrasound machine. Endothelial function was evaluated by flow mediated dilation (endothelium-dependent vasodilatation, FMD). LVM was calculated by using Devereux method. LVM index (LVMI) was obtained by dividing LVM to body surface area. Mann-Whitney U test was used to compare continuous variables, qualitative variables were compared by Chi-square test and the relations of parameters were evaluated by multiple linear regression analysis. RESULTS Both groups (hypertensive and control) were similar with respect to age, sex, left ventricular ejection fraction. IMT was significantly higher in hypertensive group (0.43+/-0.09 vs 0.33+/-0.06 mm; p<0.001). FMD values were also significantly different between hypertensive and control groups (4+/-4% vs 13+/-12%; p<0.001). LVMI was significantly different between hypertensive and control groups LVMI (124 +/- 5 vs 99+/-6 gr/m2, p=0.002). The correlation between IMT and FMD (r=0.260; p=0.026) and IMT and LVMI (r =0.348; p=0.004) were statistically significant. A correlation was found between IMT and LVMI independently of other variables (beta=105; p=0.004) when LVMI was accepted as dependent variable in multivariate linear regression analysis (R2=0.570, p<0.001). According to this finding, the 105 units increase in LVMI occurs when IMT increases by 1 mm. CONCLUSION Brachial artery IMT is related to endothelial function and LVM. According to these data, any negative changes of the IMT may reflect the similar negative changes in other parameters.

Comparision of Effects of Rosuvastatin Versus Atorvastatin Treatment on Plasma Levels of Asymmetric Dimethylarginine in Patients With Hyperlipidemia Having Coronary Artery Disease

Elevated plasma levels of asymmetric dimethylarginine (ADMA) are prevalent in patients with hypercholesterolemia and coronary artery disease. A total of 83 patients with hypercholesterolemia and angiographically documented mild coronary artery stenosis were randomized to rosuvastatin treatment (20 mg) or atorvastatin treatment (40 mg) once daily for 6 weeks after a 4-week dietary lead-in phase. Both statins decreased total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and triglyceride levels effectively. Only rosuvastatin increased high-density lipoprotein cholesterol (HDL-C) levels. Both rosuvastatin and atorvastatin decreased plasma ADMA levels; rosuvastatin had a significantly greater effect. The reduction in ADMA levels were correlated with the reduction in TC and LDL-C levels as well as LDL-C–HDL-C ratio. Treatment with rosuvastatin or atorvastatin in patients with hyperlipidemia with mild coronary artery stenosis may lead to a decrease in ADMA levels, which may contribute to improved endothelial function.

Impaired heart rate variability in patients with mitral annular calcification: an observational study.

OBJECTIVE The aim of the present study was to study time indices of heart rate variability (HRV) in patients with mitral annular calcification (MAC). METHODS A cross-sectional observational study was performed. Fifty patients with echocardiographic evidence of MAC and 50 age- and gender-matched control subjects without echocardiographic evidence of MAC were included. All the study participants underwent 2-dimensional echocardiographic examinations and 24-hour Holter monitoring for HRV analysis. Student-t, Mann-Whitney U and Chi-square tests were used for statistical analysis. RESULTS Hypertension and coronary artery disease were more common in the MAC group than in the control group. All HRV parameters including mean RR interval, SDNN, SDANN, SDNN index, pNN50 and RMSSD were reduced in the MAC group when compared with the control group (p<0.05 for all). In hypertensive subgroup, all HRV parameters except mean RR interval were diminished in patients with MAC when compared with those without MAC (p<0.05 for all). In non-hypertensive subgroup, all HRV parameters were also diminished in patients with MAC when compared with those without MAC. In the subgroup of patients with coronary artery disease, patients had lower HRV parameters except mean RR interval, pNN50 and RMSSD in comparison to those without MAC (p<0.05 for all). In the subgroup of patients without coronary artery disease, all HRV parameters were depressed in patients with MAC in comparison to those without MAC (p<0.05 for all). CONCLUSION Our findings indicate that MAC was associated with reduced heart rate variability which possibly reflects decreased parasympathetic tone with a predominant activity of the sympathetic tone.

Determination of health anxiety, anxiety, and somatosensory amplification levels in individuals with normal coronary angiography

The objective of the present study is to determine the somatosensory amplification, anxiety, and depression levels in patients with normal coronary arteries. Thirty-five patients with normal coronary arteries and 35 healthy individuals of similar age and gender as the patient group were included in the study. Somatosensory Amplification Scale (SSAS), Health Anxiety Inventory (HAI-18), Penn State Anxiety Scale (PSWQ), Beck Anxiety Inventory (BAI), and Beck Depression Inventory (BDI) were applied to all participants. Comparison of the patient group with the control group demonstrated that SSAS (22.7±8.2; 18.5±5.98; p=0.018), BAI (15.4±9.43; 9.4±7.3; p=0.004), BDI (24.9±13.5; 13.7±7.5; p<0.001), PSWQ (55.3±13.7; 33.8±6.7; p<0.001), and HAI-18 (18.8±8.7; 12.3±7.1; p=0.001) scores were statistically significantly higher in the patient group. Furthermore, a positive correlation was found between SSAS, BAI, BDI, PSWQ, and HAI-18 scores. It was found that concerns about disease prevailed in patients having normal coronary arteries, the patients continued to amplify their somatic sensations, and their anxiety and depression scores were higher than those of healthy individuals. Thus, the necessity of these interventions should be assessed in detail in the future.