Mehmet Kayrak

Red cell distribution width is independently related to endothelial dysfunction in patients with chronic kidney disease.

Background:Red cell distribution width (RDW) is a measure of erythrocyte size variability and has been shown as an independent predictor of mortality. The aim of this article was to evaluate the association of RDW with endothelial dysfunction in patients with chronic kidney disease (CKD). Methods:Patients with 1 to 5 stages of CKD were included in the study. Endothelial function was assessed with flow-mediated dilatation (FMD). Estimated glomerular filtration rate (eGFR) and carotid intima media thickness (CIMT) were determined. Clinicodemographic characteristics, biochemical values, complete blood counts, ferritin, C-reactive protein (CRP) and cholesterol levels were recorded. Spearmans correlation was used to determine correlates of RDW. Multivariate linear regression model was used to assess independent associates of FMD. Results:Overall, 367 patients with CKD 1 to 5 were included in the study. RDW showed a significant increase from stage 1 to stage 5 CKD. Median RDW was 13.5. Patients with RDW values higher than median had significantly lower hemoglobin, eGFR and FMD values and higher CIMT and CRP values compared with patients who had RDW values below median. RDW showed a significant positive correlation with the presence of diabetes mellitus, CIMT and CRP, whereas a significant negative correlation with eGFR, ferritin and FMD. Multivariate analysis showed independent predictors of FMD as RDW, presence of diabetes, hemoglobin, eGFR, CRP, and serum albumin. Conclusions:Multivariate regression model revealed RDW as a significant predictor of FMD independent of major confounding factors, such as diabetes, inflammation, anemia and kidney function in CKD.

The Relationship between Epicardial Adipose Tissue and Malnutrition, Inflammation, Atherosclerosis/Calcification Syndrome in ESRD Patients

BACKGROUND AND OBJECTIVES Malnutrition, inflammation, atherosclerosis/calcification (MIAC) and endothelial dysfunction are the most commonly encountered risk factors in the pathogenesis of cardiovascular disease in ESRD patients. Epicardial adipose tissue (EAT) is the true visceral fat depot of the heart. The relationship between CAD and EAT was shown in patients with high risk of coronary artery disease. In this study, we aimed to investigate the relationship between EAT and MIAC syndrome in ESRD patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Eighty ESRD patients and 27 healthy subjects enrolled in this cross-sectional study. EAT and coronary artery calcification score were measured by a multidetector computed tomography (MDCT) scanner. Patients with serum albumin <3.5 mg/dl were defined as patients with malnutrition; those with serum C-reactive protein level >10 ng/dl (normal range, 0-5 ng/dl) had inflammation; and those with CACS >10 had atheroscleosis/calcification. RESULTS Total CACS and EAT measurements were significantly higher in ESRD patients when compared with healthy subjects. There was a statistically significant relationship between EAT and CACS in ESRD patients (r = 0.48). EAT measurements were higher in PD patients than HD patients. Twenty-four of the patients had no component, 31 had one component, 17 had two components, and nine had all of the MIAC components. EAT was found to be significantly increased when the presence of MIAC components increased. EAT was positively correlated with age, body mass index, and presence of MIAC. These parameters were also found as independent predictors of increased EAT. CONCLUSIONS We found a relationship between EAT and components of MIAC syndrome in ESRD patients.

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.

Is Neutrophil/Lymphocyte Ratio Predict to Short-term Mortality in Acute Cerebral Infarct Independently from Infarct Volume?

BACKGROUND Neutrophil/lymphocyte ratio (NLR) is related with increased mortality in both myocardial infarction and acute ischemic stroke. It remains unclear whether NLR is a simple marker of ischemic infarct volume or an independent marker of stroke mortality. The aim of this study is to investigate the relationship of NLR with infarct volume and short-term mortality in acute ischemic stroke (AIS). METHODS This retrospective study included 151 patients with first AIS that occurred within 24 hours of symptom onset. Patients were screened from the hospitals electronic record system by using International Classification of Diseases code (G 46.8). NLR was calculated as the ratio of neutrophils to lymphocytes. Short-term mortality was defined as 30-day mortality. RESULTS A total 20 of 151 patients died during follow-up. Both NLR and infarct volume of nonsurvived group were significantly higher than survived group (P < .05). Infarct volume, NLR, and National Institutes of Health Stroke Scale (NIHSS) were independent predictors of the mortality in Cox regression analysis. The optimal cutoff value for NLR as a predictor for short-term mortality was determined as 4.81. NLR displayed a moderate correlation with both NIHSS and Glasgow Coma Scale (P < .01). NLR values were significantly higher in the highest infarct volume tertile than both in the lowest volume tertile and midtertile of infarct volume (P = .001). CONCLUSIONS NLR at the time of hospital admission maybe a predictor of short-term mortality independent from infarct volume in AIS patients. NLR should be investigated in future prospective trials investigating AIS.

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.

Prognostic Value of Neutrophil to Lymphocyte Ratio in Patients with Acute Pulmonary Embolism: A Restrospective Study

BACKGROUND Acute pulmonary embolism (PE) is a serious clinical condition characterised by a high mortality rate. Previous studies showed that leukocytosis was associated with recurrences of venous thromboemboli, major bleeding and increased mortality. The aim of the present study was to investigate the prognostic value of neutrophil to lymphocyte ratio (NLR) in patients with acute PE during short term follow-up. METHOD A total of 640 patients were screened by I26 code of ICD-9 and 359 patients were included as cases of confirmed acute PE. Admission blood counts and clinical data were obtained from medical charts. The predictors of 30-day mortality were examined. RESULTS Fifty-one out of 359 patients (14.2%) included in the study died during 30 days follow-up. In multivariate Cox regression analysis systolic blood pressure (HR:0.97 (0.94-0.99 CI95%), p=0.019), diabetes mellitus (HR:3.3 (1.30-8.39 CI95%), p=0.012), CK-MB(HR:1.03 (1.01-1.06 CI95%), p=0.024) and NLR (HR:1.03 (1.01-1.06 CI95%), p=0.008) were predictors of 30-day mortality. An optimal cut-off value of NLR was determined as 9.2 by using ROC curve. Hazards ratio of NLR>9.2 was found to be 3.60 (1.44-9.18 CI95%, p=0.006). NLR>9.2 had a sensitivity, specificity, negative predictive value, and positive predictive value of 68.6%, 80.5%, 93.9% and 36.5%, respectively. CONCLUSION NLR on hospital admission may be a predictor of 30-day mortality in acute PE. Since complete blood count is a part of the routine laboratory investigation in the most hospitalised patients use and preliminary promising results of this study, NLR should be investigated in future prospective randomised trials regarding prognostic value in acute PE.

The Relationship between Epicardial Adipose Tissue and Coronary Artery Calcification in Peritoneal Dialysis Patients

Background: Atherosclerosis, endothelial dysfunction, coronary artery calcification (CAC), and left ventricular hypertrophy are the most commonly encountered risk factors in the pathogenesis of cardiovascular disease in end-stage renal disease patients. Epicardial adipose tissue (EAT) is the true visceral fat depot of the heart. The relationship between coronary artery disease and EAT has been shown in healthy subjects and patients with a high risk of coronary artery disease. In the present study, we aimed to investigate the relationship between EAT and CAC in peritoneal dialysis (PD) patients. Patients and Methods: Forty-five PD patients (18 females, 27 males, with a mean age of 50.6 ± 15 years) and 25 healthy subjects (12 females, 13 males, with a mean age of 52.4 ± 10.7 years) were enrolled in the study. EAT and CAC score (CACS) measurements were performed by a multidetector computed tomography scanner. Results: EAT of the PD patients was significantly higher than that of the healthy subjects (p = 0.02). When patients were divided into two subgroups (group 1: CACS ≤10, n = 20; group 2: CACS >10, n = 25), EAT was also significantly higher in group 2 patients than in group 1 patients and healthy subjects. Age and EAT were also found to be correlated with CACS ≧10. Conclusion: There is a relationship between the anatomic assessment of coronary artery lesions by multidetector computed tomography and EAT in PD patients. This relationship might be attributed to increased inflammation and proinflammatory cytokines in uremic patients.

Complete atrioventricular block associated with rivastigmine therapy.

PURPOSE A case of complete atrioventricular block associated with rivastigmine use is presented. SUMMARY A 67-year-old Turkish woman with Alzheimers disease was admitted to the hospital because of dizziness and syncope. Her medical history included diagnoses of hypertension (treated with amlodipine 5 mg daily) and diabetes mellitus (treated with nateglinide 120 mg daily). She had been taking both drugs for over five years. She had also been taking rivastigmine 6 mg p.o. daily for five months for the treatment of Alzheimers disease. She had experienced dizziness since the onset of rivastigmine therapy but had not reported it to any health care provider. On admission, she had a blood pressure measurement of 90/60 mm Hg and a pulse rate of 34 beats/min. A 12-lead electrocardiogram revealed complete atrioventricular block. Echocardiography results, blood electrolyte levels, and cardiac biochemical markers were normal. After initial evaluation, a temporary transvenous pacemaker was implanted via the right femoral vein. Amlodipine and rivastigmine were discontinued. On the first day of hospitalization, a coronary angiogram revealed normal coronary anatomy. Two days later, the complete atrioventricular block resolved spontaneously to sinus rhythm. Rivastigmine 6 mg p.o. daily was reinitiated, and complete atrioventricular block recurred on the fourth day of therapy. A VVI permanent pacemaker was implanted on the fifth day of hospitalization. Amlodipine and rivastigmine were reinitiated. The patient continued rivastigmine 6 mg p.o. daily after permanent pacemaker implantation. A three-month follow-up appointment revealed that no further syncope episodes or dizziness had occurred. CONCLUSION A 67-year-old woman developed complete atrioventricular block after receiving rivastigmine for the treatment of Alzheimers disease.

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.

Uric acid level and erectile dysfunction in patients with coronary artery disease.

INTRODUCTION Erectile dysfunction (ED) is a frequent complaint of elderly subjects and is closely associated with endothelial dysfunction and cardiovascular disease (CVD). Uric acid is also associated with endothelial dysfunction, oxidative stress, and CVD, raising the hypothesis that an increased serum uric acid might predict ED in patients who are at risk for coronary artery disease (CAD). AIM This study aims to evaluate the association of serum uric acid levels with presence and severity of ED in patients presenting with chest pain of presumed cardiac origin. METHODS This is a cross-sectional study of 312 adult male patients with suspected CAD who underwent exercise stress test (EST) for workup of chest pain and completed a sexual health inventory for men survey form to determine the presence and severity of ED. Routine serum biochemistry (and uric acid levels) were measured. Logistic regression analysis was used to assess risk factors for ED. MAIN OUTCOME MEASURES The short version of the International Index of Erectile Function questionnaire diagnosed ED (cutoff score ≤ 21). Serum uric acid levels were determined. Patients with chest pain of suspected cardiac origin underwent an EST. RESULTS One hundred forty-nine of 312 (47.7%) male subjects had ED by survey criteria. Patients with ED were older and had more frequent CAD, hypertension, diabetes and impaired renal function, and also had significantly higher levels of uric acid, fibrinogen, glucose, C-reactive protein, triglycerides compared with patients without ED. Uric acid levels were associated with ED by univariate analysis (odds ratio = 1.36, P = 0.002); however, this association was not observed in multivariate analysis adjusted for estimated glomerular filtration rate. CONCLUSION Subjects presenting with chest pain of presumed cardiac origin are more likely to have ED if they have elevated uric acid levels.