Ilyas Akdemir

Frequency of silent myocardial ischemia in type 2 diabetic patients and the relation with poor glycemic control

Abstract.The aim of the study was to investigate the frequency of silent myocardial ischemia in type 2 diabetic patients without any clinical or laboratory findings of myocardial ischemia and to examine the related factors for silent myocardial ischemia. A total of 116 type 2 diabetic patients (82 women) with a disease duration of 5–20 years were included in the study. All patients underwent stress and resting myocardial perfusion single-photon emission computed tomographic (SPECT) study with 99mTc-MIBI. Coronary angiography was performed in patients with ischemia established at myocardial perfusion SPECT. Ischemia was determined in 18 (15.5%) patients by myocardial perfusion SPECT. Coronary angiography performed in 17 of these patients confirmed coronary stenosis >50% in 11 patients. Thus, the prevalence of silent myocardial ischemia was 9.6%. Significant relations were found between silent myocardial ischemia and male sex, high HbA1C level and retinopathy. Type 2 diabetic patients (especially men) with poorly controlled diabetes mellitus or retinopathy should be screened for silent myocardial ischemia.

Does exercise-induced severe ischaemia result in elevation of plasma troponin-T level in patients with chronic coronary artery disease?

Objective — It has been reported that the loss of cell membrane integrity during severe reversible ischaemia results in elevation of plasma troponin T (TnT) in unstable angina.We investigated whether TnT is released into circulation during severe ischaemia (e.g. on treadmill exercise testing) in patients with chronic coronary artery disease (CAD). Methods and results — The study comprised 54 patients who had angiographically documented CAD (22 of them had a prior history of myocardial infarction) and 18 normal subjects. All cases underwent exercise thallium (Tl)-201 SPECT myocardial perfusion imaging. Blood samples for TnT analysis were obtained for each patient at pre-exercise, immediately after and 12 hours after exercise. SPECT images were divided into 20 segments. Patients with redistribution defects ≥ 5 were considered to have severe ischaemia. Sixteen patients had severe ischaemia on SPECT images. The mean TnT levels of the patients with severe ischaemia at pre-exercise, immediately after and 12 hours after exercise were 0.009 ± 0.008, 0.012 ± 0.009 and 0.010 ± 0.010 ng/ml, respectively. In normal subjects the mean TnT levels were 0.012 ± 0.009, 0.010 ± 0.009, 0.010 ± 0.010 ng/ml, respectively.There was no significant difference neither between the two groups nor within each group with respect to pre-exercise and post-exercise TnT results. All TnT levels were within normal limits (< 0.1 ng/dl). Additionally, when the patients were grouped according to other SPECT variables (patients with reversible defects vs. fixed defects; patients with increased lung uptake of Tl-201 vs. without lung uptake; patients with transient left ventricle dilatation vs. those without) and angiographic findings (patients with multivessel disease vs. normal subjects), there were no significant differences with respect to pre-exercise and post-exercise TnT results. Conclusion — Severe ischaemia does not result in the elevation of the plasma TnT level in patients with chronic CAD.

Giant hiatal hernia presenting with stable angina pectoris and syncope: A case report

A 70-year-old woman with giant hiatal hernia presented with stable angina pectoris and three syncope attacks in the previous 3 months. Chest radiography showed marked cardiomegaly and an air-fluid level at the basal region of the heart. A mixed type large hiatal hernia that distorted the heart was detected in contrast-enhanced computed tomography and esophago gastroduodenography. Postprandial nonsustained ventricular tachycardia was present on 24- hour Holter ECG monitoring. The patients symptoms were attributed to giant hiatal hernia and improved following surgery.

Large thrombus at the site of primary sutured atrial septal defect associated with pulmonary embolism and treatment by thrombolysis.

A 53‐year‐old man with a history of repair of atrial septal defect 3‐months ago by primary suture was admitted to an emergency department with sudden onset chest pain and dyspnea. Transthoracic echocardiography revealed a large and mobile thrombus attached to the right side of the interatrial septum. The chest X ray and perfusion lung scan established the diagnosis of the multiple pulmonary emboli. Doppler examination of the venous system for a possible source of thrombus was unremarkable. The postoperative early appearance of thrombus and multiple pulmonary emboli defects at lung scan supported that thrombus was originated from the primary suture site. Thrombolytic treatment achieved complete resolution of the thrombus both in the pulmonary artery and at the repaired septal defect site. The patient was placed on warfarin and thrombus was not detected by transesophageal echocardiography at the 9‐month follow‐up. (ECHOCARDIOGRAPHY, Volume 20, August 2003)

Effect of homocysteine-lowering therapy on vascular endothelial function and exercise performance in coronary patients with hyperhomocysteinaemia.

Objective — This study was performed to determine the effect of homocysteine-lowering therapy (HLT) on endothelium-dependent vasodilation (EDD) and exercise performance in patients with coronary artery disease. Methods and Results — Among the patients who were on the waiting list for coronary intervention, 26 male patients (plasma homocysteine (Hcy) levels >15 mol/l) who had a focal stenosis of at least 70% in the left anterior descending artery were included in the study.The patients were matched to receive HLT (n = 15; 0.4 mg of folic acid, 2 mg vitamin B6 and 6 g of vitamin B12) or placebo (n = 11) until the coronary intervention was performed (mean 3.8±0.9 weeks). Brachial artery vasomotion test and treadmill stress testing were performed at baseline and 4 weeks after HLT before the time of coronary intervention in each patient. Hcy levels were found to be decreased significantly after HLT compared to baseline (23.4±6 vs. 11.3±4 mol/l; p<0.001) whereas placebo had no effect. HLT but not placebo produced a marked improvement in EDD, from 3.9±1.1% to 9.4±2.3% (p<0.0001). Endothelium-independent nitroglycerin-induced dilation was similar in the HLT and placebo groups compared with the baseline. In the exercise testing, HLT resulted in a significant improvement in exercise duration and reduction in the amount of maximal ST-segment depression, (from 6.5±2 to 6.9±2 min, p = 0.02 and from 1.2±0.7 to 0.8±0.5 mm, p = 0.01, respectively) whereas placebo did not. Conclusion — Lowering Hcy levels improves EDD and exercise performance while reducing the exercise-induced myocardial ischaemia in patients with coronary heart disease and hyperhomocysteinaemia.

Angiotensin-converting enzyme gene polymorphism and coronary heart disease in Turkish type 2 diabetic patients.

OBJECTIVE It has been suggested that the insertion (I)/deletion (D) polymorphism of the angiotensin-converting enzyme (ACE) may be associated with atherosclerosis. The aim of the study was to examine the association between ACE gene polymorphism and coronary heart disease in Turkish type 2 diabetic patients. METHODS AND RESULTS A total of 152 (97 female, 55 male) type 2 diabetic patients were included into the study. All patients underwent myocardial perfusion scintigraphic examination and forty-five of them with a perfusion defect underwent coronary angiography.Thirty-eight patients with a coronary stenosis of more than 50% on coronary angiography were considered as having coronary heart disease. The I/D polymorphism was determined by polymerase chain reaction. There was no statistically significant difference in genotypic and allelic frequencies of the ACE I/D polymorphism among patients with and without coronary heart disease (DD:ID:II (%), 32:58:11 and 39:44:17, respectively). CONCLUSIONS ACE gene polymorphism is not a significant parameter to determine coronary heart disease in Turkish type 2 diabetic patients.Objective — It has been suggested that the insertion (I)/deletion (D) polymorphism of the angiotensin-converting enzyme (ACE) may be associated with atherosclerosis.The aim of the study was to examine the association between ACE gene polymorphism and coronary heart disease in Turkish type 2 diabetic patients. Methods and results — A total of 152 (97 female, 55 male) type 2 diabetic patients were included into the study. All patients underwent myocardial perfusion scintigraphic examination and forty-five of them with a perfusion defect underwent coronary angiography.Thirty-eight patients with a coronary stenosis of more than 50% on coronary angiography were considered as having coronary heart disease.The I/D polymorphism was determined by polymerase chain reaction.There was no statistically significant difference in genotypic and allelic frequencies of the ACE I/D polymorphism among patients with and without coronary heart disease (DD:ID:II (%), 32:58:11 and 39:44:17, respectively). Conclusions — ACE gene polymorphism is not a significant parameter to determine coronary heart disease in Turkish type 2 diabetic patients.

Large Ascending Aortic Aneurysm and Severe Aortic Regurgitation in a 7-year-Old Child with Marfan Syndrome and a Review of the Literature: Marfan Syndrome in Childhood

A year 7-old-girl was admitted because of dyspnea on exertion and palpitations. Her symptoms had gradually worsened for the last 6 months. She had physical features of the Marfan syndrome. Transthoracic echocardiography showed an ascending aortic aneurysm, severe aortic regurgitation and mildly dilated left ventricle. Because of marked aortic aneurysm and severe aortic regurgitation, the patient was treated with a β-blocker and an angiotensin converting enzyme inhibitor. Surgery was refused by her parents. We describe here a child with Marfan syndrome in whom significant dilatation of the ascending aorta and severe aortic regurgitation is encountered and major cardiovascular complications of Marfan syndrome were reviewed.

QT dispersion in the risk stratification of patients with unstable angina: correlation with clinical course, troponin T and scintigraphy

Objective — This study sought to evaluate the potential prognostic usefulness of QT dispersion (QTd) in patients with unstable angina. Methods and results — QTd was calculated and plasma troponin T (TnT) level was measured and rest perfusion imaging with Tc-99m sestamibi was performed in 62 patients admitted with chest pain at rest. All patients had a follow-up during one month in order to assess cardiac events. Cardiac events occurred in 41 patients (no deaths, 11 myocardial infarctions (MI), 4 urgent and 26 planned revascularizations).The mean QTd in patients with cardiac events was significantly higher than in those without cardiac events (68 ± 28 vs. 54 ± 14 ms; p = 0.01).When patients were divided into subgroups according to the cardiac events, the mean QTd in MI and revascularization were 90 ± 25 ms and 60 ± 25 ms, respectively. QTd in patients with MI was higher than in patients without cardiac events (p = 0.001). There was no significant difference in QTd between the revascularization subgroup and patients without cardiac events. Nineteen patients with elevated TnT had a greater QTd compared to patients with normal TnT (74 ± 29 vs. 56 ± 20 ms; p = 0.008). Additionally, the mean QTd in 46 patients with perfusion defects was slightly higher than in patients without (66 ± 27 vs. 53 ± 17 ms; p = 0.03).There was also a moderate correlation between QTd and the number of perfusion defects (r = 0.31, p = 0.01). On the other hand, most of the patients who had a MI or urgent revascularization had a QTd greater than 75 ms. Conclusion — The measurement of QTd in patients with unstable angina may help to stratify patients at high risk for cardiac events, in particular MI and urgent revascularization.

Acute rest perfusion imaging in high risk unstable angina: association with troponin T and clinical endpoints

Background: Troponin T (TnT) and rest perfusion imaging (RPI) have been reported to be important diagnostic tools for risk stratification in patients with chest pain. Methods: We investigated the association between two methods in 60 patients presenting with typical chest pain at rest within the last 6 h before admission. All patients underwent Tc-99m gated SPECT imaging and serial TnT measurements and were followed for occurrence of adverse cardiac events up to 30 days.Results: Perfusion defect was detected in 42 patients and elevated TnT was observed in 23 patients. All of the patients with an elevated TnT have also perfusion defect in RPI. Half of the patients with normal TnT level (51%) presented a perfusion defect detected by RPI (p = NS). The patients with elevated TnT levels had more perfusion defect numbers than those with normal TnT levels (8.2 ± 2.9 vs. 5.3 ± 2.2; p = 0.0007). Cardiac events occurred in 38 patients (14 MI, 24 revascularisation). In predicting cardiac events, RPI and TnT had sensitivities (97 vs. 58%; p < 0.001), specificities (77 vs. 95%, p = NS), positive predictive values (PPV) (88 vs. 96%; p = NS) and negative predictive values (NPV) (94% vs. 57%; p = NS), respectively. In predicting MI, the two tests had sensitivities (93 vs. 93%; p = NS), specificities (37 vs. 78%; p < 0.001), PPVs (31 vs. 57%; p = NS) and NPVs (94 vs. 97%; p = NS), respectively. Conclusions: These results suggest that in patients with rest angina (1) TnT elevation is associated with the extent of myocardial perfusion defect; (2) both tests are valuable, while positive RPI is more sensitive in predicting all cardiac events irrespective of TnT; both positive TnT and positive RPI predict a high probability to have MI; (3) both negative test results predict a very low probability to have cardiac event, including MI.

Bubbles in the Heart

To the Editor: The image by Catapano et al1 gives misleading information concerning bubbles in the heart in patients with prosthetic valves. They speculated that “bright particles” seen in the left ventricular cavity are consistent with gas bubbles that occur in scuba divers after hypobaric decompression. We disagree with this speculation, because this phenomenon is well documented in patients with prosthetic valves. In their large series, Gencbay et al2 found a strong correlation between serum lactic dehydrogenase levels and quantity of bubbles. They suggested hemolysis as a cause of bubble formation. Moreover, Kaymaz …