Kurtulus Ozdemir

Intravenous N-acetylcysteine plus high-dose hydration versus high-dose hydration and standard hydration for the prevention of contrast-induced nephropathy: CASIS—A multicenter prospective controlled trial

BACKGROUND Contrast-induced nephropathy (CIN) is a leading cause of acute renal failure and affects mortality and morbidity. We investigated the efficacy of prophylactic intravenous (IV) N-acetylcysteine (NAC) and hydration for the prevention of CIN in patients with mild to moderate renal dysfunction who are undergoing coronary angiography and/or percutaneous coronary intervention (PCI). METHODS A total of 220 patients who had mild to moderate renal dysfunction with serum creatinine (SCr) ≥ 1.1mg/dL or creatinine clearance ≤ 60 mL/min were randomized in 3 groups: 80 patients were assigned to IV NAC plus high-dose hydration with normal saline, 80 patients to only high-dose hydration with normal saline and 60 patients to standard hydration with normal saline (control group). The primary end point was the alteration of SCr level. The secondary end point was the development of CIN after the procedure. RESULTS SCr levels changed the least in the NAC plus high-hydration group (P=0.004). The rate of the CIN in the NAC plus high-dose hydration group was also lower than the high-dose hydration group (P=0.006). No significant differences in the primary and secondary end points were found between high-dose hydration and control group. CONCLUSION The results of this study suggest that NAC plus high-dose hydration was superior to high-dose hydration alone as well as standard hydration for the protection of renal functions in patients with mild to moderate renal dysfunction who are undergoing coronary angiography and/or PCI. High-dose hydration without NAC was not better than standard hydration alone.

Comparison of myocardial performance index obtained either by conventional echocardiography or tissue Doppler echocardiography in healthy subjects and patients with heart failure

This study was planned to investigate the normal reference values of myocardial performance index (MPI) obtained by tissue Doppler echocardiography (TDE) and the agreement between MPI measured by TDE and conventional MPI measured by pulsed-wave Doppler (PWD) in healthy subjects and patients with heart failure (HF). Two hundred and three patients with HF and 190 healthy subjects were enrolled in this study. Isovolumic contraction and relaxation time (ICT and IRT) and ejection time (ET) were measured from mitral inflow and left ventricular (LV) outflow. Tissue Doppler echocardiography recordings were obtained at the septal, lateral, inferior, and anterior of the mitral annulus and same time intervals were measured. Myocardial performance index was calculated. The functional capacity of the patients with HF was determined according to New York Heart Association classification. TDE-MPI values were higher than conventional PWD-MPI values in both groups (53% ± 8% vs 48% ± 11%, P < 0.0001 in the healthy subjects; 84% ± 21% vs 72% ± 19%, P <0.0001 in the patients with HF). Moderate agreement was found between PWD-MPI and LV mean TDE-MPI in both groups. In identifying patients with moderately or severely decreased LV ejection fraction, TDE-MPI had higher cutoff values than conventional PWD-MPI, and TDE-MPI had higher specificity, sensitivity, negative predictive value, and diagnostic accuracy. In patients with HF, TDE-MPI had a stronger correlation with LV ejection fraction and functional capacity than did PWD-MPI. TDE-MPI is an alternative to conventional PWD-MPI in assessment of cardiac function. However, the higher MPI cutoff points should be considered when this method is used for the evaluation of cardiac function.

Value of lead aVR in predicting acute occlusion of proximal left anterior descending coronary artery and in-hospital outcome in ST-elevation myocardial infarction: an electrocardiographic predictor of poor prognosis

BACKGROUND We aimed to investigate the value of ST elevation in lead aVR (ST upward arrow aVR) in predicting the left anterior descending coronary artery (LAD) occlusion site proximal to first septal perforator (S(1)) and its effect on in-hospital outcome in ST-elevation myocardial infarction (STEMI). METHODS The study included 950 patients with STEMI. Patients were divided into 2 groups as aVR(+) and aVR(-) according to the presence of an ST upward arrow aVR of 0.5 mm or greater. RESULTS ST elevation in lead aVR was seen in 155 (16%) patients, and LAD occlusion proximal to S(1) was detected in 52% of patients in the aVR(+) group and in 9% of patients in the aVR(-) group. aVR positivity was associated with higher heart rate, lower systolic blood pressure and ejection fraction, and worse Killip class at the hospital admission. In-hospital mortality was 19% in the aVR(+) group and 5% in the aVR(-) group. aVR positivity was an independent predictor of in-hospital death. CONCLUSION This study revealed that ST upward arrow aVR was not only a good indicator of LAD occlusion proximal to S(1) but also a source of valuable information about in-hospital outcome in patients with STEMI.

A unique double right coronary artery abnormality

Double right coronary artery is a very rare coronary artery abnormality. Two cases have been reported so far. In these cases, both right coronary arteries were giving the same branches, and originated from the same orifice. In our case, both right coronary arteries were giving different branches.We could not find such a case in the literature.Therefore, we consider our case a unique double right coronary artery abnormality.

Short Communication: Assessment of exercise stress testing with artificial neural network in determining coronary artery disease and predicting lesion localization

The aim of this study is to show the artificial neural network (ANN) on determination of coronary artery disease existence and localization of lesion based upon exercise stress testing (EST) data. EST and coronary angiography were performed on 330 patients. The data studied acquiring 27 verifying features was normalized employing z-score method. To select training and test data, 10-fold cross-validation methods were involved and multi-layered perceptron neural network was employed for the classification. The interpretation of EST using ANN proved 91%, 73% and 65% diagnostic accuracy for the left main coronary (LMCA), left anterior descending and left circumflex coronary arteries, respectively. Besides, 69% for the right coronary artery is also predicted. For the LMCA, a 94% negative predictive value (NPV) was obtained. This high percentage of NPV encourages the elimination of LMCA lesions. Some knowledge can also be obtained about lesion localization, besides diagnosing of coronary artery disease by the assessment of EST via ANN.

The Effect of Nondipping Blood Pressure Patterns on Cardiac Structural Changes and Left Ventricular Diastolic Functions in Normotensives

Background: Cardiac structural changes have been reported to be more prominent in nondipper normotensives than the dipper ones. But the influence of nondipping status on cardiac diastolic functions of normotensives has not been studied yet. In this study, we investigated the effect of nondipping status on both cardiac structural changes and left ventricular (LV) diastolic functions in normotensives. Methods: We performed ambulatory blood pressure (BP) monitoring (ABPM) and echocardiography in 62 normotensive subjects with the following criteria: (1) office BP < 140/90 mmHg; (2) average 24‐hour ambulatory BP < 130/80 mmHg. Results: In the evaluation by tissue Doppler imaging (TDI), the early diastolic myocardial peak velocity (Em) and Em/late diastolic myocardial peak velocity (Am) ratio (Em/Am ratio) were lower in nondippers than those in dippers (P = 0.009 and P < 0.001, respectively). Isovolumic relaxation time (IRT) and myocardial performance index (MPI) were higher in nondippers than those in dippers (P = 0.036 and P = 0.026, respectively). Nondipping status, independent of other factors, was observed to cause both a decrease in the Em and Em/Am ratio and an increase in IRT. However, its effect on IRT was not statistically significant (coefficient =−0.27, P = 0.027; coefficient =−0.37, P = 0.002; coefficient = 0.20, P = 0.082, respectively). Conclusions: Nondipping of nocturnal BP seems to be a determinant of cardiac remodeling and LV diastolic dysfunction (LVDD) and may result in a cardiovascular (CV) risk independent of the increase in LV mass (LVM) in normotensives.

Association of pulmonary artery obstruction index with elevated heart-type fatty acid binding protein and short-term mortality in patients with pulmonary embolism at intermediate risk

PURPOSE Heart-type fatty acid binding protein (H-FABP) is a sensitive marker of myocardial injury and predictor of worse prognosis in patients with pulmonary embolism (PE). Assessment of right ventricular dysfunction and pulmonary artery obstruction index (PAOI) with computed tomography (CT) has been reported as a predictor of mortality in PE. Therefore, we aimed to assess the correlation between H-FABP and CT angiographic PAOI in PE patients at intermediate risk. MATERIALS AND METHODS Sixty-one patients (28 males; mean age, 62 ± 17 years) with diagnosis of PE were included in this study. CT was performed in all patients, and the following parameters were evaluated: right ventricle/left ventricle ratio (RV/LV), pulmonary artery axial diameter, superior vena cava axial diameter, and PAOI determined with Qanadli score. Blood samples were assessed for H-FABP and troponin levels. Patients were followed for 30 days after discharge. RESULTS Mean PAOI was 57 ± 18%. Eleven patients died during the follow-up period due to PE (18% mortality rate). H-FABP was positive in 21 patients (35%). There was no difference in CT parameters between patients with positive H-FABP and negative H-FABP. In addition, CT parameters were similar between patients who survived and those who did not. RV/LV ratio correlated with PAOI score. Among the biomarkers, troponin levels correlated with both RV/LV ratio and PAOI. H-FABP was an independent predictor of mortality. PAOI and RV/LV ratio did not predict 30-day mortality. CONCLUSION Although H-FABP positivity confers a bad prognosis on PE patients at intermediate risk, PAOI did not predict mortality in this group.

Reliability and efficacy of metoprolol and diltiazem in patients having mild to moderate mitral stenosis with sinus rhythm

The authors evaluated the effects of beta blockers (metoprolol) and calcium channel blockers (diltiazem) in patients having mild to moderate mitral stenosis (MS) with sinus rhythm. Eighty patients with a complaint of dyspnea with diagnosed MS were included in this study. Patients were randomized into metoprolol and diltiazem groups. The first group received oral diltiazem treatment for 3 months following an IV dose of 25 mg diltiazem. The second group received oral metoprolol for 3 months following an IV dose of 5 mg metoprolol. All patients performed a treadmill exercise test at the beginning of and after 3 months of treatment. Transthoracic echocardiographic studies were also performed following the IV drug administration and after 3 months of treatment. In addition, oxygen uptakes of patients were measured before and after the stress and after 3 months of treatment. Decreases in peak gradient (PG) and mean transmitral gradient (MG) were observed in the metoprolol group after IV and oral metoprolol treatment. A prolongation of exercise time in treadmill exercise test (TET) and a decrease in the maximum heart rate after oral metoprolol treatment were noted. Eighteen patients in the metoprolol group had benefited symptomatically from this treatment and complaints of dyspnea were alleviated, whereas no symptomatic relief was seen in the diltiazem group. No significant prolongation was observed in effort times (p>0.05) of the diltiazem group. Transmitral gradients measured via echocardiographic examination did not change (p>0.05). With respect to oxygen uptake rates, a statistically significant decrease was determined in the metoprolol group, whereas no difference was found in diltiazem group. The authors conclude that metoprolol may be useful in patients with MS and can provide symptomatic relief. They did not observe any beneficial effect of diltiazem in these patients.

Analysis of 24-hour heart rate variations in patients with epilepsy receiving antiepileptic drugs

OBJECTIVE The goal of the study described here was to evaluate interictal heart rate variability (HRV) in young patients with epilepsy, a patient population in whom sudden unexpected death in epilepsy (SUDEP) is known to be more common. METHODS Twenty-four-hour ambulatory ECG Holter recordings of 37 patients (15-40 years old) and 32 healthy controls were compared. RESULTS All of the time domain indices (SDNN, SDANN, RMSSD, and HRV triangular index) were significantly suppressed (P<0.001), and there was a marked reduction in parasympathetic tone (reduced HF(nu,)P<0.001) and an increase in sympathetic tone (increased LF(nu) and LF/HF ratio, P<0.001) in the patient group. Stepwise linear regression analysis revealed that polytherapy and epilepsy duration >10 years were independent variables associated with a reduction in SDNN. CONCLUSION Our data suggest that the major determinants of suppressed SDNN are polytherapy and epilepsy duration >10 years. Analysis of spectral measures of frequency domain indices suggests that an increased sympathetic tone in association with a decreased parasympathetic tone may constitute the mechanism underlying SUDEP in young people with epilepsy.

Comparison of increased aspirin dose versus combined aspirin plus clopidogrel therapy in patients with diabetes mellitus and coronary heart disease and impaired antiplatelet response to low-dose aspirin.

The effects of therapy with aspirin 300 mg/day and with combined aspirin 100 mg/day plus clopidogrel 75 mg/day on platelet function were compared in patients with diabetes mellitus and coronary artery disease and impaired antiplatelet responses to aspirin 100 mg/day. The study population consisted of 151 outpatients with type II diabetes mellitus and coronary artery disease who were taking aspirin 100 mg/day. Of the 151 patients, a subgroup of subjects with impaired aspirin response were selected on the basis of the results of platelet aggregometry. Nonresponsiveness to aspirin was defined as mean aggregation > or =69% with 3 micromol/L adenosine diphosphate and mean aggregation > or =70% with 2 micromol/L collagen. Aspirin semiresponders were defined as meeting 1 but not both of these criteria. Nonresponders and semiresponders were randomized equally to aspirin 300 mg/day and aspirin 100 mg/day plus clopidogrel 75 mg/day, and aggregation tests were repeated after 2 weeks. Sixty of the 151 patients with diabetes (40%) were found to respond to aspirin inadequately. Platelet aggregation induced by adenosine diphosphate and collagen decreased significantly after aspirin 300 mg/day or combined therapy. Combined treatment was found to have a stronger inhibitory effect on platelet aggregation induced by adenosine diphosphate than aspirin 300 mg/day (p = 0.002). Impaired aspirin response was resolved by increasing the aspirin dose or adding clopidogrel to aspirin (p <0.0001 for each). However, desired platelet inhibition was achieved in significantly more patients by combined treatment than by aspirin 300 mg/day (p <0.05). In conclusion, aspirin 100 mg/day does not inhibit platelet function adequately in a significant number of patients with diabetes mellitus and coronary artery disease. Increasing the aspirin dose to 300 mg/day or adding clopidogrel to aspirin can provide adequate platelet inhibition in a significant number of those patients with impaired responses to low-dose aspirin.