Mehmet Sıddık Ülgen

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.

The relationship between angiotensin-converting enzyme (insertion/deletion) gene polymorphism and left ventricular remodeling in acute myocardial infarction.

BackgroundThe development of left ventricular remodeling after acute myocardial infarction is a predictor of heart failure and mortality. The genetic influence on cardiac remodeling in the early period after acute myocardial infarction, is however, unclear. The aim ofthis study was to investigate the relationship between angiotensin-converting enzyme (ACE) gene polymorphism and left ventricular remodeling in the early period in patients with anterior myocardial infarction. MethodThe study population consisted of 142 patients with their first attack of acute anterior myocardial infarction. Echocardiographic examinations were performed within 24 h of the first attack (first evaluation) and on the fifth day of acute myocardial infarction (second evaluation). Left ventricular end systolic and diastolic diameters, left ventricular end systolic and diastolic volumes, ejection fraction, mitral flow velocities (E, A, E/A), deceleration time, isovolumic relaxation time and myocardial performance index were calculated. ACE I/D polymorphism was determined using polymerase chain reaction amplification. ResultsOn the basis of polymorphism of the ACE gene, the patients were classified into the three groups: group 1, deletion/deletion (n=59) genotype, group 2 insertion/deletion (n=69), and group 3 insertion/insertion (n=14) genotype. When the first and second sets of echocardiographic results of the groups were compared, all parameters were not different among three groups. In group analysis, Left ventricular systolic diameters, left ventricular diastolic diameters, left ventricular end diastolic diameters, left ventricular ejection fraction and myocardial performance index between first and second echocardiographic results were significantly different in deletion/deletion group and only myocardial performance index and left ventricular ejection fraction in insertion/deletion group (P<0.05). ConclusionsACE gene polymorphism may influence early cardiac remodeling after acute myocardial infarction. Patients with the deletion/deletion–insertion/deletion genotype may be particularly more sensitive to ACE-I treatment possibly owing to the more prominent role of the renin–angiotensin system.

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.

Plasma concentrations of soluble CD40 ligand in smokers with acute myocardial infarction: a pilot study

Coronary artery disease (CAD) is believed to be the single leading cause of death in both men and women in the world. Smoking is the most important risk factor for CAD. Smoking increases platelet aggregation and thrombus formation. CD40 ligand (CD40L) is a transmembrane glycoprotein derived from activated platelets. It participates in thrombus formation during the acute phase of acute myocardial infarction (MI). Elevation of CD40L identifies the patients who are at highest risk for cardiac events and who are likely to benefit from treatment with the glycoprotein IIb/IIIa (GPIIb/IIIa) receptor antagonists. The purpose of this study was to evaluate levels of CD40L in smokers with acute MI. Fifty-seven patients with acute MI were enrolled in this study. Thirty-one smokers were compared with 26 non-smokers. Soluble CD40L level in the plasma was determined by a standard enzyme-linked immunosorbent assay. Circulating levels of CD40L were higher in the smokers’ group. Smokers with acute MI may have increased risk for thrombotic complications during acute MI, and optimal antiaggregant therapy should be administered.

Is There Any Relationship between Metabolic Parameters and Left Ventricular Functions in Type 2 Diabetic Patients without Evident Heart Disease

Background: The aim of the present study was to evaluate left ventricle (LV) systolic and diastolic function, using tissue Doppler echocardiography (TDE) and color M‐mode flow propagation velocity, in relation to blood glucose status in normotensive patients with type 2 diabetes mellitus (T2DM) who had no clinical evidence of heart disease. Methods: Seventy‐two patients with T2DM (mean age 49.1 ± 9.8 years) without symptoms, signs or history of heart disease and hypertension, and 50 ages matched healthy controls (mean age 46.1 ± 9.8 years) had echocardiography. Systolic and diastolic LV functions were detected by using conventional echocardiography, TDE and mitral color M‐mode flow propagation velocity (VE). Fasting blood glucose level (FBG) after 8 hours since eating a meal, postprandial blood glucose level (PPG), and HbA1C level were determined. The association of FBG, PPG and HbA1C with the echocardiographic parameters was investigated. Results: It was detected that although systolic functions of two groups were similar, diastolic functions were significantly impaired in diabetics. No relation of FBG and PPG with systolic and diastolic functions was determined. However, HbA1C was found to be related to diastolic parameters such as E/A, Em/Am, VE and E/VE (β=−0.314, P = < 0.05; β=–0.230, P < 0.05; β=–0.602, P < 0.001, β= 0.387, P < 0.005, respectively). In addition to HbA1C, LV, diastolic functions were also correlated with age and diabetes duration. Conclusion: Diastolic LV dysfunction may develop even in absence of ischemia, hypertension, and LVH in T2DM. FBG and PPG have no effect on LV functions, but HbA1C levels may affect diastolic parameters.

Atrial Fibrillation in Turkey: Epidemiologic Registry (AFTER) study design.

OBJECTIVE Atrial fibrillation (AF) is an important health problem in Turkey. However, no prospective, multicenter, large trial reflecting national data has been published so far. Therefore, the aim of this study was to follow, analyze and evaluate patients with AF in a large multicenter nation-wide trial. METHODS Two thousand three hundred consecutive patients with AF in their electrocardiogram, reflecting all the population of seven geographical regions of Turkey will be included in the study. The patients will be followed up for two years and death, transient ischemic attack, stroke, systemic thromboembolism, major bleeding, hospitalization will be recorded as the primary end-point. RESULTS Will be available at the end of the study; preliminary results will be due December 2012. CONCLUSION General risk profile of patients with AF, frequency of anticoagulation, frequency of effective treatment and risks of bleeding will be evaluated according to the current guidelines. Major adverse events and their independent predictors will be determined.

A comparison of blood pressure and pulse pressure values obtained by oscillometric and central measurements in hypertensive patients

Abstract Objective. Wide pulse pressure (PP) affects the accuracy of oscillometric blood pressure measurements (OBPM): however, the degree of this impact on different patient groups with wide PPs is unclear. This study will investigate the accuracy of OBPM in achieving target BP and PP in isolated systolic hypertension (ISH) group compared with mixed hypertension (MHT) group. Method. A total of 115 patients (70 with ISH and 45 with MHT) were enrolled in the study. Upper arm and wrist OBPM, obtained by OmronM3 and OmronR6 devices respectively, were compared with the simultaneously measured values from the ascending aorta. The ISH was defined as a systolic blood pressure (SBP) ≥140 mmHg and a diastolic blood pressure (DBP) <90 mmHg. MHT was defined as a SBP≥140 mmHg and a DBP≥90 mmHg. Results. The mean central arterial blood pressure (BP) and central PP were higher in the ISH group than those in the MHT group. The upper arm OBPM underestimated the central SBP in two groups (−5 mmHg, −3 mmHg, p=0.5, respectively), but overestimated DBP in the ISH group compared with MHT patients (6.8 mmHg, 1 mmHg, p=0.04, respectively). Wrist OBPM similarly underestimated to the central SBP in each group (−16 mmHg, −19 mmHg, p=0.15), whereas the sum of overestimation of DBP was significantly higher in the ISH than in the MHT group (+6 mmHg, − 1 mmHg, p=0.001, respectively). Also, each of the devices underestimated the central PP in the ISH group (about 10 mmHg) as being higher than that of the MHT group. Conclusion. Oscillometric devices may be used for self-BP measurement in patients with ISH without clinically important disadvantages compared with the patients with MHT. For PP measurement in patients with ISH, there were substantial differences between intra-arterial and indirect arm BP measurements.

The effect of glucose-insulin-potassium solution on ventricular late potentials and heart rate variability in acute myocardial infarction.

BackgroundBlunted heart rate variability (HRV) and presence of ventricular late potentials (VLPs) are known to correlate with an increased risk of ventricular tachycardia and sudden cardiac death in acute myocardial infarction (AMI). In the present study, we investigated the effect of glucose–insulin–potassium (GIK) solution on the VLPs and HRV in AMI. MethodsSeventy‐two consecutive patients with first Q wave AMI were randomized to GIK solution and placebo. HRV analysis and ambulatory electrocardiographic recordings were taken in all patients between 24 and 48 h. Sub‐maximal exercise testing and echocardiography were performed and signal‐averaged electrocardiography (SAECG) was recorded before discharge. ResultsTotal filtered QRS duration (FQRS: 102 ± 7 versus 108 ± 11 ms;P  < 0.05), low‐amplitude signal (LAS: 25 ± 8  versus 32 ± 11 ms;P  < 0.01) and frequency of VLPs (21 versus 45%;P  < 0.05) were found to be significantly lower while root‐mean‐square voltage of the terminal 40 ms of QRS (RMS‐40: 45 ± 18  versus 36 ± 20 μV;P  < 0.05), and left ventricular ejection fraction (EF: 55 ± 6 versus 48 ± 7;P  < 0.05) were significantly higher in the GIK group when compared to placebo. During the hospital period, the presence and frequency of post‐myocardial infarction angina were significantly lower in the GIK group (15 versus 29%, P  < 0.05), whereas an insignificant decrease in frequency of ventricular arrhythmias was observed in these patients. On HRV analysis, there was no significant difference between two groups in either time domain (SD, SDNN, RMS‐SD) or frequency domain (HF, LF, LF/HF ratio) parameters. ConclusionGIK solution may be beneficial to VLPs, ischaemic events, and left ventricular systolic performance in the early period of AMI. This therapy has no significant effect on HRV in AMI patients.

Epicardial Fat Tissue Predicts Increased Long-Term Major Adverse Cardiac Event in Patients With Moderate Cardiovascular Risk

We investigated the relationship between epicardial fat volume (EFV) measured by multislice computed tomography (MDCT) and long-term major adverse cardiac events (MACEs). Consecutive patients (n = 564) were enrolled in this retrospective study. Patients were divided into tertiles according to EFV. Patients were followed up for an average of 18 months. Patients in each tertile were similar in terms of gender and risk factors. Patients with greater EFV in the third group were more likely to be overweight (P = .001) and older (P = .001). High-density lipoprotein cholesterol levels were relatively lower in the third tertile (45 ± 9, 45 ± 11, and 43 ± 9 mg/dL, respectively; P = .018). The third group had a significantly higher rate of myocardial infarction (0.6%, 1.1%, and 3.7%, respectively; P = .043). The incidence of MACEs during the follow-up period was highest in the third group 15.9% (4.1%, 7.7%, and 15.9%, respectively; P = .001). Epicardial fat volume measured by MDCT was associated with increased long-term cardiovascular risk.

Completely asymptomatic proximal aortic dissection and massive bullous lung disease: coincidence or is there any etiologic link?

This case report focuses on a completely asymptomatic proximal aortic dissection in a middle-aged male smoker with bullous lung disease. The possibility of a relationship between A1-antitrypsin (A1AT) deficiency and aortic dissection is discussed in light of the recent data.