Hatem Ari

Exaggerated blood pressure response to exercise--a new portent of masked hypertension.

Masked hypertension (MHT) is a popular entity with increased risk of developing sustained hypertension, heart attack, stroke, and death. Subjects have normal blood pressure (BP) at office but elevated values at night so it is difficult to diagnose. Exaggerated blood pressure response to exercise (EBPR) is also a predictor of future hypertension. To investigate the relationship between these two entities, we evaluated 61 normotensive subjects with EBPR. The subjects underwent 24-h ambulatory blood pressure monitoring (ABPM). The prevalence of masked hypertension among subjects with EBPR was 41%%. Body mass index (BMI), non-high density lipoprotein (HDL) cholesterol, diastolic blood pressure (DBP) at peak exercise and recovery, nondipping DBP pattern, and elevated early morning average BPs were associated with masked hypertension. In multivariate logistic regression analysis, the DBP measured at peak exercise was detected as an independent predictor of MHT in subjects with EBPR. Subjects with abnormally elevated BP during exercise are prone to MHT, necessitate medical assessment and close follow-up for hypertension.

Delirium Following Acute Myocardial Infarction: Incidence, Clinical Profiles, and Predictors

PURPOSE To examine the incidence, clinical profile, and predictors of delirium following acute myocardial infarction (MI). DESIGN AND METHODS The study sample included 212 consecutive patients with acute MI who were admitted to the coronary intensive care unit of a university hospital. FINDINGS Delirium was found to occur in 5.7% of the patients. The predictors of delirium were advanced age, higher level of serum potassium at admission, and experience of cardiac arrest during MI. PRACTICE IMPLICATIONS Delirium is reasonably prevalent in patients with acute MI. We propose that patients with the risk factors that have been delineated in this study should be evaluated carefully.

The relation between Lp-PLA2 levels with periodic limb movements

ObjectiveLipoprotein-associated phospholipase A2 (Lp-PLA2), a novel marker of vulnerable plaque to prone rupture, is a predictor of both cardiovascular event and cerebrovascular event, and highly sensitive-C-reactive protein (hs-CRP) is an acute-phase response protein implicated in a broad range of cardiovascular diseases. We aimed to examine the association between periodic limb movements in sleep (PLMs) with circulating Lp-PLA2 and hs-CRP levels in patients with PLMs.MethodsSeventy patients with newly diagnosed PLM with polysomnography were enrolled this study. Patients were divided into two groups according to PLM index (normal PLM index, <15; elevated PLM index, ≥15). Lp-PLA2 and hs-CRP concentrations were measured in serum samples by turbidimetric and nephelometric methods, respectively. The concentrations of these parameters were compared between two groups and correlation analysis was performed between PLMs and Lp-PLA2 and hs-CRP levels.ResultsLp-PLA2 levels and hs-CRP were significantly increased in elevated PLM index group compared with the control group (206.8 ± 78.1 vs 157.8 ± 56.7, p = 0.003, and 4.2 ± 3.5 vs 2.4 ± 2.1, p = 0.02, respectively). PLM index was positively correlated with Lp-PLA2 levels (r = 0.40, p = 0.001) and hs-CRP (r = 0.24, p = 0.05). In the linear regression model, Lp-PLA2 was an independent predictor of PLM index (R2 = 0.36, p = 0.005).ConclusionThis study demonstrated an independent linear relation between PLM index and Lp-PLA2. In addition, it was seen increased Lp-PLA2 and hs-CRP levels in patients with elevated PLM index. Based on these results, we can suggest that risk of vascular events may be increased in patients with PLMs and with increased PLM index.

The effects of spironolactone on atrial remodeling in patients with preserved left ventricular function after an acute myocardial infarction: a randomized follow-up study.

ObjectivesAtrial remodeling is an important part of cardiac remodeling after acute myocardial infarction (AMI). The aim of this study was to evaluate the effect of spironolactone on atria in patients with preserved left ventricular (LV) functions after AMI by using two-dimensional and tissue Doppler imaging techniques (TDI). MethodsThe study consisted of 110 patients with AMI, successfully revascularized with percutaneous coronary intervention, ejection fraction greater than or equal to 40%, and Killip class I–II. Patients were randomized into two groups: conventional therapy (n=55) and additional spironolactone of 25 mg/day with standard conventional therapy (n=55). Echocardiography was performed in the first 48–72 h of AMI and during 6 months of follow-up. Left atrial volume index and emptying fraction were obtained. The peak regional atrial contraction velocity, the time between the onset of p-wave on the monitor ECG and the onset, peak, and the end (TE) of the atrial contraction wave on the tissue Doppler technique curve were measured. ResultsThe left atrial volume index and left atrium (LA) dimensions did not significantly change in either group. In the spironolactone group, left atrial emptying fraction increased compared with both baseline value (from 53.0±0.16 to 57.0±0.13 P=0.011) and conventional therapy group (from 50.0±0.17 to 47.0±0.16, P=0.013). The atrial contraction velocity did not change but the LA–TE, interatrial septum–TE, and right atrium–TE were prolonged in the conventional therapy group. ConclusionAdditional spironolactone therapy provided a little benefit on LA remodeling and atrial electromechanic properties in patients with AMI and preserved LV functions.

A Bizarre Electrocardiographic Pattern Due to Chronic Lithium Therapy

Cardiotoxicity that results from lithium overdose is uncommon and electrocardiographic (ECG) changes are rarely reported. However, some authors have specifically reported the occurrence of ischemic ECG changes due to a lithium overdose. This article describes a case that is demonstrating ECG changes that mimic inferior myocardial infarction during the course of chronic lithium treatment and showing QTc prolongation in this patient. The patients’ ECG changes were partially recovered after hemodialysis.

Assessment of left ventricular systolic and diastolic function with conventional and tissue Doppler echocardiography imaging techniques in patients administered tyrosine kinase inhibitor.

OBJECTIVES The aim of this study was to use echocardiographic techniques to determine the possible cardiotoxic effects of low molecular weight tyrosine-kinase inhibitors (TKI) in patients receiving the therapy for the first time. STUDY DESIGN Thirty patients (17 females; 13 males; mean age 49±16; range 22 to 76 years) who met the exclusion criteria and were diagnosed as having malignancy were enrolled. All patients underwent conventional echocardiography and tissue Doppler imaging (TDI) prior to the treatment. The conventional echocardiogram was repeated 2 months later as the patients were concurrently receiving therapy. Myocardial Performance Index was obtained by conventional echocardiography and by TDI techniques to evaluate left ventricular systolic and diastolic function. RESULTS Statistically significant increase occurred in mean left ventricle (LV) end-systolic volume. However, there was significant decrease in both mean LV ejection fraction and LV stroke volume values (64±3, 62±4, p=0.000 and 67±13, 61±13, p=0.000, respectively). Anterior wall Em/Am ratio measured by using the TDI technique was significantly decreased at the end of two months (0.99±0.49, 0.90±0.41, p=0.03). In addition, decreases were determined in Sm values obtained from all of four LV walls and also in mean Sm value, but this decrease was significant only for the lateral wall Sm measurement (12.8±2.9, 11.6±2.3, p=0.004). CONCLUSION Tyrosine-kinase inhibitors therapy can be administered safely to patients without predisposing factors for cardiotoxicity in short treatment intervals, and low molecular TKIs may cause subtle or clinically significant cardiotoxicity following the treatment period even in patients without predisposing factors for cardiotoxicity, so clinicians should consider this possibility.

Relationship between heart-type fatty acid-binding protein levels and coronary artery disease in exercise stress testing: an observational study

OBJECTIVE Although, there has been great improvement on the diagnosis and early treatment of acute coronary syndromes, especially in terms of myocardial damage biochemical markers, we do not have a specific marker yet, for using the diagnosis of stable coronary artery disease (CAD). This study aimed to evaluate the relationship between CAD and the changes of heart-type fatty acid binding protein (H-FABP) levels before and after exercise stress testing (EST). METHODS A total of 47 patients were enrolled in this observational study. Of 47 patients, 21 had normal coronary anatomy; the remaining 26 patients had coronary lesions over 70% in at least one major coronary artery. All patients performed EST. Along with this, H-FABP levels before EST and at peak exercise, 1st hour, 3rd hour (3h), were measured in all patients. Differences among the measurements were evaluated through the Friedman test and Wilcoxon test, and the Bonferroni correction was applied to determine which measurement caused the difference. RESULTS Contrary to expectations, the means of the H-FABP values measured at particular intervals for each group tended to decline from the basal level to the 3h level. When the difference between the 3h measurement and the basal level was compared in each group, the decreasing was statistically significant in both groups (p<0.05). A statistically significant decrease at the 3h measurement compared to the basal level in the CAD group was more apparent than in the control group (2.790±2.569 ng/ml vs. 0.837±2.070 ng/ml, p=0.009). CONCLUSION We found that H-FABP levels did not increase during EST and contrary to expectation, were inclined to decrease. We thought that decreasing H-FABP levels likely resulted from exercise-induced proteinuria.

Aortic propagation velocity does not correlate with classical aortic stiffness parameters in healthy individuals

Objective: Aortic stiffness is an important cardiovascular risk marker, which can be determined using different noninvasive techniques. Aortic propagation velocity (APV) has recently been established as a novel echocardiographic parameter of aortic stiffness. This study aimed to investigate the association between APV and the classical echocardiography-derived aortic stiffness parameters, aortic distensibility (AD) and aortic strain (AS), in a group of otherwise healthy individuals. Methods: In total, 97 consecutive healthy subjects were recruited in this observational study. APV was measured using color M-mode echocardiography from the suprasternal window in the descending aorta. AS and AD were calculated using clinical blood pressure and the M-mode echocardiography-derived aortic diameters. Correlation analyses were performed between cardiovascular risk factors related to increased aortic stiffness (age, obesity, and blood pressure) and measured stiffness parameters (APV, AS, and AD). Correlation analyses were also performed among the measured stiffness parameters. Results: Good correlation of age, blood pressure, and BMI with AS and AD was observed. One-on-one correlation of age, blood pressure, and BMI with APV was not observed. No correlation was observed between APV and AS (r=–0.05, p=0.6) or between APV and AD (r=–0.17, p=0.8). Conclusion: Although APV has been proposed as a novel and practical echocardiographic parameter of aortic stiffness, especially in patients with coronary artery disease, correlations between classical stiffness parameters (AS and AD) and APV were absent in healthy individuals at low–intermediate risk. The clinical and research applicability of APV should be further evaluated.

Low atrial rhythm mimics myocardial infarction.

Answer: 683 A 55-year-old male patient was admitted to an emergency department of a secondary care hospital with left forearm pain and numbness of fingers lasting for 6 h. He did not state any kind of chest pain and has not had any cardiac disease history and risk factors except smoking for 30 years. Electrocardiography (ECG) demonstrated negative P waves and ST-segment elevation in inferior leads and minimal ST-segment depression in D1 and aVL, and heart rate was 101 bpm (Fig. 1). His cardiac examination and vital signs were normal. He was transported to our hospital for primary percutaneous coronary intervention with the diagnosis of inferior myocardial infarction (MI). Which of the following is not included in your first differential diagnosis in light of the clinical and electrocardiographic findings?

Echocardiographic imaging of saccular aneurysm in the left main coronary artery.

A 59-year-old woman presented with a recent onset of dyspnea and chest pain. Past medical history and cardiovascular examination were completely normal. Electrocardiography demonstrated sinus rhythm with left bundle branch block pattern. Transthoracic echocardiography (TTE) revealed a slightly reduced ejection fraction with hypokinetic septal and anterior walls. Parasternal short-axis imaging displayed a small saccular echo-free space associated with the aorta, and no color flow turbulence was observed with color flow Doppler imaging (Fig. 1a). Subsequently, two-dimensional transesophageal echocardiography (2D-TEE) revealed a normal long-axis view and similar short-axis findings to transthoracic imaging. Real-time 3D-TEE (RT-3D-TEE) provided better imaging and indicated that the saccular body was a round-shaped small aneurysm that was relevant to the left main coronary artery (LMCA) take-off location (Fig. 1b; Video 1). Aortography depicted a round-shaped saccular aneurysm, 8×9 mm in size, originating from the proximal LMCA that was approximately 2–3 mm next to the LMCA ostium (Fig. 2a; Video 2). Coronary angiography revealed an aneurysm associated with proximal LMCA (Fig. 2b; Video 3). Although TTE can provide valuable information regarding the diagnosis of coronary aneurysm in pediatric patients with Kawasaki disease, its validity is limited in adults because of the declining image quality. Nevertheless, proximal segments of the coronary arteries can be assessed with TEE. RT-3-D-TEE can provide even better information regarding the location, size, shape, and relation to adjacent tissue in LMCA aneurysm, as in our case. In this report, we presented an isolated saccular LMCA aneurysm diagnosed by echocardiography, which is rarely encountered in coronary angiography.