Hilal Olgun Kucuk

Neutrophil-to-Lymphocyte Ratio May Predict Contrast-Induced Nephropathy

We read with interest the article ‘‘Neutrophil-to-lymphocyte ratio predicts contrast-induced nephropathy in patients undergoing primary percutaneous coronary intervention’’ by Kaya et al. They investigated the relationship between neutrophilto-lymphocyte (N/L) ratio and contrast-induced nephropathy (CIN) in patients with ST-segment elevation myocardial infarction (STEMI). They demonstrated a relationship between N/L ratio and CIN development in patients with STEMI undergoing primary percutaneous coronary intervention. They also demonstrated an independent association between N/L ratio and CIN development in patients with STEMI undergoing coronary angiography. A full blood count is a cheap method that provides information about red and white cells, platelets, count and dimensions of subgroups of cells, and parameters like red cell distribution width, platelet cell distribution width, and mean platelet volume. Routine peripheral blood counts may be useful in risk stratification of patients with CIN. The white blood cell (WBC) count is one of the inflammatory biomarkers. Although the WBC may be within the normal range, subtypes of WBC, as expressed by the N/L ratio, may predict all-cause mortality. The N/L ratio is an easy, cheap, noninvasive, and widely available laboratory marker used to evaluate systemic inflammation. The N/L ratio has received increased attention due to its role as an independent prognostic factor for coronary artery disease (CAD), hypertension, chronic kidney disease, diabetes, heart failure, cerebrovascular disease, peripheral arterial disease, and malignancy. It can also be affected by atherosclerotic risk factors such as smoking, alcohol consumption, hypercholesterolemia, metabolic syndrome, nonalcoholic liver disease, abnormal thyroid function tests, and older age. Furthermore, acute bacterial and viral infections may change the N/L ratio. Additionally, medications such as antihypertensive therapy including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, b-blockers, and statins may influence the N/L ratio. It would be useful and the results might be different, if the authors described these factors. The CIN is a serious complication of PCI. The CIN is one of the most important reasons of hospital-acquired renal failure. The CIN can cause prolonged hospitalization, increased cost and incidence of renal and cardiovascular events, and mortality. Elderly patients are at greater risk of CIN because of decreased renal reserve. In addition, some factors like glomerular filtration rate (GFR) 200 mL were identified as risk factors for CIN after PCI. Alcohol consumption and arterial blood pressure before contrast exposure may be associated with increased risk of CIN in patients. Hypertriglyceridemia, metabolic syndrome, impaired fasting glucose, and multivessel disease may also be associated with the higher incidence of CIN. Also, some medications including a renin–angiotensin–aldosterone system medications may be related to CIN. Finally, they used the Cockcroft-Gault equation to calculate the GFR. The modification of diet in renal disease (MDRD) is another method for calculating the GFR. However, the Cockcroft-Gault equation may estimate lower GFR in younger age groups compared with the MDRD formula, but it can measure higher GFR in older individuals compared with the MDRD formula. The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) recently published an equation for GFR using the same variables (serum creatinine level, age, sex, and race) as the MDRD formula. However, the CKD-EPI equation more accurately categorized individuals with respect to longterm clinical risk of incident end-stage renal disease, all-cause mortality, coronary heart disease, and stroke compared with the MDRD formula. In addition, even mild chronic kidney dysfunction such as a GFR <90 mL/min and dehydration was also a risk factor for CIN. In conclusion, these findings will enlighten further studies about N/L ratio as a surrogate marker of risk stratification in

An overlooked cause of resistant hypertension: upper airway resistance syndrome - preliminary results

OBJECTIVE: Upper airway resistance syndrome is a sleep-disordered breathing syndrome that is characterized by repetitive arousals resulting in sympathetic overactivity. We aimed to determine whether upper airway resistance syndrome was associated with poorly controlled hypertension. METHODS: A total of 40 patients with resistant hypertension were enrolled in the study. All of the patients underwent polysomnographic examinations and 24-hour ambulatory blood pressure monitoring to exclude white coat syndrome and to monitor treatment efficiency. Among 14 upper airway resistance syndrome patients, 2 patients had surgically correctable upper airway pathologies, while 12 patients were given positive airway pressure therapy. RESULTS: All patients underwent polysomnographic examinations; 22 patients (55%) were diagnosed with obstructive sleep apnea and 14 patients (35%) were diagnosed with upper airway resistance syndrome, according to American Sleep Disorders Association criteria. The patients with upper airway resistance syndrome were younger and had a lower body mass index compared with other patients, while there were no difference between the blood pressure levels and the number of antihypertensive drugs. The arousal index was positively correlated with systolic blood pressure level (p = 0.034; rs = 0.746), while the Epworth score and AHI were independent of disease severity (p = 0.435, rs = 0.323 and p = 0.819, rs = -0.097, respectively). Eight patients were treated with positive airway pressure treatment and blood pressure control was achieved in all of them, whereas no pressure reduction was observed in four untreated patients. CONCLUSIONS: We conclude that upper airway resistance syndrome is a possible secondary cause of resistant hypertension and that its proper treatment could result in dramatic blood pressure control.

The neutrophil lymphocyte ratio may be useful inflammatory indicator before applying other expensive and invasive procedures

Dear Editor, We read with interest article the entitled “Relation between platelet indices and branch retinal vein occlusion (BRVO) in hypertensive patients” by Onder et al.[1] They aimed to evaluate MPV in BRVO. They reported that MPV was significantly higher in patients with BRVO. The ready availability of MPV measurements at no additional cost may encourage its wider use in clinical practice. Retinal vein occlusion is the most common retinal vascular occlusive disorder and is usually associated with a variable amount of loss of vision. Generally, branch retinal vein occlusion (BRVO) tends to be considered as one disease which is not only incorrect, but also cause of most of the confusion on the subject. A complete blood count is a relatively routine, inexpensive, practical, and easy examination that supplies additional information. MPV is a widely used laboratory marker associated with platelet function based on inflammatory conditions and thrombosis.[2] Recently, increased levels of MPV were demonstrated in cerebrovascular disease, peripheral artery disease, stroke, malignancy, gastrointestinal diseases, atrial fibrillation,[3] all of that are associated endothelial dysfunction on the basis of inflammation.[4] The higher MPV values are mentioned to be a beneficial marker of higher thromboycte activity and have been found to be associated with inflammation in patients with thyroid and rheumatic diseases. Platelet parameters might be influenced by coronary risk factors including age, obesity, smoking, diabetes mellitus, hypertension, hyperlipidemia, metabolic syndrome, and deep vein thrombosis. Furthermore, MPV value was found to be also higher in chronic obstructive pulmonary disease and nonalcoholic hepatic disease patients compared with a control group. Therefore, it may be interesting if the authors[1] provided information about these conditions. Finally, not only MPV, but also red cell distribution width, neutrophil lymphocyte (N/L) ratio,[5] plateletcrit, platelet lymphocyte (P/L) ratio, C-reactive protein (CRP), gamma-glutamyl transferase (GGT), and uric acid are easy methods to evaluate the BRVO in hypertensive patients. These markers might be useful in clinical practice. We suggest that MPV ought to be evaluated together with other serum inflammatory markers such as N/L ratio, P/L ratio, GGT and uric acid.

Varicocele: tissue stress in the etiology.

BACKGROUND/AIM It is accepted that red blood cell distribution width (RDW) is a novel prognostic marker that reflects oxidative stress and chronic inflammation. In this study, we aimed to investigate the correlation between RDW and varicocele, the etiology of which has not fully elucidated yet. This study also aimed to study the mean platelet volume (MPV) values of the patient and control group. MATERIALS AND METHODS RDW and MPV levels were measured in 50 varicocele subjects (group 1) and 48 healthy controls (group 2) from January 2012 to January 2014, retrospectively. RESULTS MPV levels were significantly higher in group 1 than in group 2 (P < 0.001). Although the relationship was weak, the patients with varicocele had significantly lower RDW values than did the controls (r: 0.24 P = 0.026). Positive correlations were not found between varicocele grade and MPV and RDW values (P < 0.05). CONCLUSION Higher MPV values are associated with increased odds of developing varicocele.

Importance of neurobiological mechanisms in depression

We have read the article titled “Association between Socioeconomic Factors and Depression among Cardiovascular Patients Living in Rich Resourced Middle Eastern Country” written by Tam Truong Donnelly with great interest [1]. This article highlights the impact of heterogeneous socioeconomic factors on cardiovascular patients with depression as well as the importance of collaborative management to improve both mental and physical conditions in this population. The author reported that some socioeconomic and demographic factors like unemployment, being full-time homemaker, female sex, and lowmonthly incomewere associatedwith depression in cardiovascular patients. Depression is among the most debilitating disorders worldwide while it is associated with significant disability and low quality of life by its own apart from comorbidities. Although association between socioeconomic factors and depression has been demonstrated, endogenous factors also play a role in the pathophysiology of the disease. According to some authors, endogenous depression is classified as a subtype of depression. Recent studies showed that depression has been associated with neuroendocrinological and neuroinflammatory factors such as immune system dysregulation with increased activity of proinflammatory cytokines, hypothalamic-pituitary–adrenal axis activation resulting in hypercortisolemia, and autonomic system

Relationship Between Neck Circumference and Epicardial Fat Thickness in a Healthy Male Population

Background: Epicardial fat is an upper body visceral fat depot that may play a significant role in the development of adverse metabolic and cardiovascular risk profiles. There is a significant direct relationship between the amount of epicardial fat and general body adiposity (body mass index, BMI), but data regarding subcutaneous adiposity is limited. Objective: We conducted a study to determine the association between neck circumference and epicardial fat thickness in healthy young male individuals, and assess their individual correlations with general body adiposity and cardiometabolic risk factors. Methods: One hundred consecutive male patients aged 18 years or older with no known major medical conditions were included in the study. All participants underwent detailed physical examination including measurement of blood pressure, weight, height, waist/hip ratio, and neck circumference. Blood was collected to determine fasting glucose and lipid parameters. A standard echocardiographic examination was performed with additional epicardial fat thickness determination. Results: Among 100 study participants, neck circumference correlated significantly with weight, waist circumference, BMI, blood glucose, serum total cholesterol, low-density (LDL)-cholesterol, and triglycerides levels. No significant correlation was found between neck circumference and high-density lipoprotein (HDL)-cholesterol levels. Neck circumference correlated moderately and positively with echocardiographic epicardial fat thickness. Conclusion: Among patients with low cardiometabolic risk, increased neck circumference was associated with increased epicardial fat thickness.

eComment. Thrombus strikes back: promising role of thromboelastography for thromboembolic risk prediction in HeartMate II recipients.

Heart failure is a major public health problem representing the ultimate stage of various cardiovascular diseases. Currently left ventricular assist devices (LVADs) have been increasingly used for the management of patients with end-stage heart failure. Every year approximately 4000 LVADs are implanted in the US; approximately three-quarters of these are HeartMate II. The HeartMate II is a small, continuous flow, rotary, left-sided heart pump approved by the FDA for bridge to transplantation in cardiac transplant candidates with the advantages of smaller size, less invasive surgical implantation procedure and low dose anticoagulation requirement. However, according to a recently published paper based on pooled data from 895 patients with the HeartMate II LVAD device, the thrombosis rate occurring early after implantation is nearly four times higher than rates seen in pre-approval clinical trials [1]. Karimi et al. reported that thrombelastography (TEG) guided antiplatelet therapy reduces the late onset bleeding rate in HeartMate II recipients [2]. Thrombelastography is a superb coagulation test which has the advantage of combining multiple data obtained from various coagulation tests into a single read-out. Furthermore, TEG gives information about platelet function, clot strength, and fibrinolysis which other coagulation tests cannot provide. Prompted by the manuscript of Karimi et al, we speculate that TEG could be a useful test for predicting thrombotic risk in HeartMate II recipients. Haemostasis occurs with orchestrated function of platelets, clotting factors and vascular endothelium. Thrombelastography provides an effective and convenient means of monitoring the entire coagulation cascade which can traditionally be measured via several conventional tests. Thrombelastography is a promising test for predicting thrombosis [3]. It demonstrates a hypercoagulable state that is not detected by prothrombin time or partial thromboplastin time. Conventional coagulation tests cannot assess factors predicting thromboembolic risk such as clot strength and degree of clot dissolution [4]. In summary, HeartMate II recipients have surprisingly high device thrombosis rates. Since these patients are also at risk for bleeding complications, anticoagulation should be carefully titrated. The art of LVAD-implanted patient management is weighing the risk between haemorrhagic and thromboembolic events. Thrombelastography may guide clinicians while making challenging decisions. Conflict of interest: none declared

An unusually fast developing giant saphenous vein graft aneurysm.

A 68-year-old man with a history of hypertension and hypercholesterolemia was seen with non–ST-segment elevation myocardial infarction. He had undergone coronary artery bypass grafting in 1996. Coronary angiography was performed, revealing a giant aneurysm of saphenous vein graft (SVG) to the proximal descending artery (Figure 1, A). Because of its large size, contrast was observed only over the outer border.

Is Aortic Valve Sclerosis Always a Surrogate Marker for Atherosclerosis

Aortic valve sclerosis (AVS) is no longer considered a benign consequence of aging, rather it is a presumptive marker for underlying atherosclerosis. Established cardiovascular risk factors such as age, male gender, smoking, hypertension, and hyperlipidemia are also risk factors for AVS. Besides overlapping clinical factors, AVS and atherosclerosis also share common pathophysiological mechanisms including basement membrane disruption, lipid deposition, and inflammatory cell infiltration. The recent article by Korkmaz et al is additional proof of this association demonstrating decreased ankle brachial index values in asymptomatic participants with AVS as well as higher prevalence of AVS in patients with asymptomatic peripheral artery disease (PAD). However, AVS has unique factors acting on disease processes such as calcium metabolism disorders and chronic kidney disease. A possible direct association with ionized calcium and an inverse one with total serum calcium and phosphorus were previously shown. Valve calcification in the setting of uremia was attributed to either chronic inflammation or metabolic dearrangements and is observed from the early stages of renal impairment. In order to demonstrate a more definitive relationship between AVS and PAD on the basis of a common atherosclerosis hypothesis, patients with chronic kidney disease should be excluded or the groups should be well matched in terms of serum creatinine levels.

Occupational exposure to hand-arm vibration

a Siyami Ersek Thoracic and Cardiovascular Surgery, Training and Research Hospital, Department of Cardiology, Istanbul, Turkey b Department of Cardiology, Special Izmir Avrupa Medicine Center, Karabaglar, Izmir, Turkey c Gulhane Military Medical Academy, Haydarpasa Training Hospital Department of Cardiology, Istanbul, Turkey d Gulhane Military Medical Academy, Department of Cardiology, Ankara, Turkey