Meryem Aktoz

Decreased nocturnal synthesis of melatonin in patients with coronary artery disease

In human beings, cardiovascular activity has a distinct circadian variation: Heart rate, blood pressure, and vascular tone decrease at night. Nocturnal cardiovascular blunting is at least partially linked to the autonomic activity and increased risk of cardiac and cerebral events. To assess whether decreased nocturnal melatonin synthesis and secretion in coronary artery disease (CAD), we investigated nocturnal secretion pattern of melatonin in patients with CAD and healthy subjects. The present study performed in 16 patients with angiographically documented CAD (aged 46-71 years) and in nine healthy controls (aged 36-66 years). Blood samples were collected every 2 h between 22:00 and 08:00 h. Melatonin levels were measured with a commercially available radioimmunoassay kit. We found large interindividual variation in the pattern of melatonin secretion in both groups. Patients with CAD secreted less nocturnal melatonin at 02:00, 04:00 and 08:00 h than control subjects (P=0.014, P=0.04 and P=0.025, respectively). Peak and Delta melatonin (peak-lowest melatonin) were found lower in patients with CAD (48.6 [19.1-75.4] vs. 131.4 [67.8-137.2] pg/ml, P=0.006 and 43 [10.5-68.5] vs. 107.6 [55.7-113.1] pg/ml, P=0.002, respectively). Peak time of melatonin secretion was observed earlier in patients with CAD (02:00 h [23:00-02:00 h] vs. 03:45 h [02:00-05:00 h], P=0.04). Our study provides useful and preliminary information about decreased nocturnal melatonin synthesis and release in patients with CAD might help physicians in managing these patients.

Impaired nocturnal synthesis of melatonin in patients with cardiac syndrome X

We investigated nocturnal secretion pattern of melatonin in patients with cardiac syndrome X and healthy subjects. The present study performed in five patients with cardiac syndrome X and in nine healthy controls. Blood samples from all subjects were collected every 2 h intervals between 22:00 and 08:00 h. Melatonin levels were measured with a radioimmunoassay kit. Patients with cardiac syndrome X secreted less nocturnal melatonin at 02:00 h than control subjects (P=0.04). Peak and Delta melatonin (peak-lowest melatonin) were found lower in patients with cardiac syndrome X (P=0.039 and P=0.028, respectively). In conclusion patients with cardiac syndrome X show a markedly decreased nocturnal melatonin synthesis. Our study provides useful information about melatonin synthesis and release in patients with cardiac syndrome X might help physicians in managing these patients.

Asymmetrical dimethylarginine and severity of erectile dysfunction and their impact on cardiovascular events in patients with acute coronary syndrome.

Introduction Coronary artery disease (CAD) and vascular erectile dysfunction (ED) are related to endothelial dysfunction. Elevated asymmetrical dimethylarginine (ADMA) levels and ED are common in patients with increased cardiovascular risk. Our aim was to investigate whether ADMA has a predictive role for major adverse cardiovascular events (MACE) in acute coronary syndrome (ACS). The secondary aim of this study was to investigate whether severity of ED predicts MACE in these patients. Material and methods Follow-up data were available for severity of ED in 71 patients with ACS. Plasma ADMA levels were determined by ELISA in 57 patients. Erectile dysfunction was assessed by the International Index of Erectile Function-6 (IIEF-6) score. Major adverse cardiovascular events (reinfarction, all-cause hospitalisation, stroke and all-cause death) was evaluated after a median of 10 months. Results Severe ED had no significantly increased hazard ratio for cardiovascular events compared with mild, mild to moderate, and moderate ED (0.259 [95% CI 0.041–1.6], p = 0.147; 0.605 [95% CI 0.095–3.8], p = 0.594; 0.980 [95% CI 0.233–4.1], p = 0.978; and 0.473 [95% CI 0.052–1.3], p = 0.508). The patients who had ADMA levels ≥ 0.32 µmol/l had no significantly increased hazard ratio for cardiovascular events compared with patients who had ADMA levels < 0.32 µmol/l (2.018 [95% CI 0.615–6.6], p = 0.247). Conclusions Severity of ED and ADMA did not increase the risk of cardiovascular events in follow-up patients with ACS in our study. Larger prospective studies are necessary to evaluate whether ADMA predicts cardiovascular events in patients with ACS.

Arrhythmias following Revascularization Procedures in the Course of Acute Myocardial Infarction: Are They Indicators of Reperfusion or Ongoing Ischemia?

Objective. The most important step in the treatment of ST elevation myocardial infarction is to sustain myocardial blood supply as soon as possible. The two main treatment methods used today to provide myocardial reperfusion are thrombolytic therapy and percutaneous coronary intervention. In our study, reperfusion arrhythmias were investigated as if they are indicators of coronary artery patency or ongoing ischemia after revascularization. Methods. 151 patients with a diagnosis of acute ST elevation myocardial infarction were investigated. 54 patients underwent primary percutaneous coronary intervention and 97 patients were treated with thrombolytic therapy. The frequency of reperfusion arrythmias following revascularization procedures in the first 48 hours after admission was examined. The relation between reperfusion arrhythmias, ST segment regression, coronary artery patency, and infarct related artery documented by angiography were analyzed. Results. There was no statistically significant difference between the two groups in the frequency of reperfusion arrhythmias (P = 0.355). Although angiographic vessel patency was higher in patients undergoing percutaneous coronary intervention, there was no significant difference between the patency rates of each group with and without reperfusion arrythmias. Conclusion. Our study suggests that recorded arrhythmias following different revascularization procedures in acute ST elevation myocardial infarction may not always indicate vessel patency and reperfusion. Ongoing vascular occlusion and ischemia may lead to various arrhythmias which may not be distinguished from reperfusion arrhythmias.

Parachute mitral valve abnormality and bicuspid aortic valve in an asymptomatic adult patient

Transesophageal echocardiography of a 54-year-old asymptomatic man revealed a bicuspid aortic valve (Figure 1, upper left panel) and elongated chordae converging and inserting into one of the papillary muscles. There was a redundant anterior mitral leaflet, as well as a rudimentary posterior leaflet during systole (Figure 1, upper right panel). Mitral commissural and a two-chamber view during diastole demonstrated a papillary muscle and elongated chordae, as well as a parachute-like mitral valve abnormality (Figure 1, bottom left and right panels). Figure 1) Transesophageal echocardiography revealing a bicuspid aortic (Ao) valve (upper left panel), a redundant anterior mitral leaflet (AML) and a rudimentary posterior leaflet during systole (upper right panel). Mitral commissural and two-chamber view during ... Parachute mitral valve is a rare congenital cardiac anomaly in which the chordae tendinae of both leaflets of the mitral valve insert into a single papillary muscle. This is called a ‘true parachute’ mitral valve, whereas the presence of two papillary muscles, with all chordae inserting into one muscle, is called a ‘parachute-like’ mitral valve (1). A true parachute mitral valve is usually associated with mitral stenosis and may cause symptoms early in life. Despite the presence of moderate mitral regurgitation, the asymptomatic course of our patient until adulthood may likely be explained by the absence of mitral stenosis.

Management of a patient with active rheumatoid arthritis and suspected tuberculosis causing effusive-constrictive pericarditis

In the following case report we present a patient who has been admitted for pericardial effusion causing cardiac compression with active rheumatoid arthritis and suspected tuberculosis. The patient was successfully treated with intravenous pulse steroid for active rheumatoid arthritis, with prophylactic anti-tuberculosis agents for suspected tuberculosis and with surgical pericardiectomy for the thickened pericardium as well as recurrent pericardial effusion.

Evaluation of subendocardial and subepicardial left ventricular functions using tissue Doppler imaging after complete revascularization.

Objective: We aim to evaluate subepicardial and subendocardial left ventricular (LV) functions in patient single coronary artery lesion at early stage after percutaneous coronary intervention (PCI). Additionally, a comparison of LV functions between patients and control cases was aimed. Method: Patients with culprit left anterior descending (LAD) lesion (n = 25) and subjects with normal coronary angiography (n = 25) were evaluated. Patients underwent PCI and at least one coronary stent was placed. After PCI, the pulsed‐wave tissue Doppler imaging (pw‐TDI) parameters taken from subepicardial and subepicardial layers were compared among the patients. Results: Left atrium (P = 0.050), LV end‐diastolic (P = 0.049), and end‐systolic (P = 0.006) diameters were larger compared to the control group. LV inflow velocities were not different between the patient and the control group. But, the myocardial performance index was different (P = 0.049). The systolic and diastolic pw‐TDI parameters were apparently different between the patient and the control group. While the systolic pw‐TDI parameters did not change, the diastolic pw‐TDI parameters taken from both subepicardial (circumferential contraction) and subendocardial layers (longitudinal contraction) improved after PCI. After PCI, it was shown that while Ea velocity (P = 0.012) taken from the subendocardial layer increased, IVRa velocity (P < 0.001) taken from the subepicardial layer decreased. Conclusion: In our study, it could be said that LV, left atrium, and aortic valve diameter increase in patients with coronary artery disease. The systolic and diastolic functions were impaired at subendocardial and subepicardial layers. These dysfunctions can be easily presented with pw‐TDI. Although systolic dysfunction persists, diastolic dysfunction improves at early stage after PCI.

Clinical significance of positive isovolumetric relaxation velocity of pulsed-wave tissue Doppler imaging.

Objective: Among the pulsed‐wave tissue Doppler imaging (pw‐TDI) parameters, there are two different pw‐TDI velocities (IVRa and IVRb) after systolic velocity, but before Ea velocity. In our study, we investigated the clinical importance of these two velocities in left ventricular diastolic dysfunction (LVDDF) evaluation. Methods: One hundred and eighty cases without exclusion criteria were included in the study. Cases with a transmitral E to A flow (E/A) ratio below 1 were assigned to group 2. In cases with an E/A ratio between 1 and 2, the pw‐TDI parameters were taken into consideration. Cases with an Ea/Aa ratio above 1 were assigned to group 1 and cases with an Ea/Aa ratio 1 or below than 1 were assigned to group 3. Group 1 (n: 68) represented normal diastolic left ventricular (LV) inflow while group 2 (n = 87) represented impaired relaxation and group 3 (n = 25) represented pseudonormal LV inflow. Results: In our study, we found that IVRa velocity was lower in group 1 compared to group 2 and group 3 (P < 0.001 and P = 0.038, respectively). Similarly, this velocity was significantly different in group 3 and group 2 such as it was higher in group 2 compared to group 3 (P = 0.022). There was no difference in IVRb velocity and IVRa/IVRb ratio among the groups. A negative correlation was found between IVRa velocity and Ea velocity (r = 44%, P < 0.001). Positive correlation was found between IVRa velocity and isovolumetric relaxation time (r = 18%, P = 0.014) and also between IVRa velocity and Aa velocity (r = 19%; P = 0.010). Conclusion: Based on the results of our study, we concluded that IVRa velocity is an important pw‐TDI parameter in the evaluation of LVDDF, especially in differentiating pseudonormal LVDDF type from normal LV inflow.

A new parameter of pulsed-wave tissue Doppler imaging: IVRa.

Objective: We investigated how velocity of isovolumetric relaxation period on pulsed‐wave tissue Doppler trace (IVRa and IVRb) is affected by the left ventricular (LV) geometry changes. Methods: Two hundred cases without exclusion criteria were included in the study. Normal LV mass index (LVMI) and normal relative wall thickness (RWT) was assigned to group 1 (n = 72). Concentric remodeling (normal LVMI and increased RWT) was defined to group 2 (n = 25). Eccentric LV hypertrophy (LVH) (increased LVMI and normal RWT) was defined to group 3 (n = 62). And finally, concentric LVH (increased LVMI and increased RWT) was defined to group 4 (n = 41). Results: Patients with LVH (groups 3 and 4) were older than group 1 (P = 0.017 and 0.001). It was observed in the assessment of M‐mode ECHO parameters that the aortic valve diameter, aortic valve opening, LV end‐systolic diameter (LVESD), LV end‐diastolic diameter (LVEDD), and left atrium (LA) were higher in cases with eccentric LVH. It was shown that Ea velocity and Sa velocity time integral (Sa‐VTI) were decreased with LV geometry change. However, IVRa velocity and E/Ea were increased as LV geometry change. A positive correlation between IVRa velocity and LVMI (correlation ratio = 34%, P = 0.000) was found. Similarly, a positive correlation between IVRa velocity and RWT (correlation ratio = 17%, P = 0.025) was found. Conclusion: IVRa velocity exhibits a positive correlation with LV geometry changes indicating that IVRa velocity is affected by LV geometry like the other parameters influenced by LV geometry.

Non-Sustained Ventricular Tachycardia Episodes Predict Future Hospitalization in ICD Recipients with Heart Failure

Background Implantable cardioverter-defibrillator (ICD) therapy is well known to reduce mortality in selected patients with heart failure (HF). Objective To investigate whether monitored episodes of non-sustained ventricular tachycardia (NSVT) might predict future HF hospitalizations in ICD recipients with HF. Methods We examined 104 ICD recipients (mean age: 60 ± 10.1 years, 80.8 % male) with HF who were referred to our outpatient clinic for device follow-up. After device interrogation, patients were divided into NSVT positive and negative groups. The primary endpoint was the rate of hospitalization within the next 6 months after initial ICD evaluation. Results Device evaluation demonstrated at least one episode of monitored NSVT in 50 out of 104 patients. As expected, no device therapy (shock or anti-tachycardia) was needed for such episodes. At 6 months, 24 patients were hospitalized due to acute decompensated HF. Hospitalization rate was significantly lower in the NSVT negative as compared with positive groups (38% versus 62%; adjusted hazard ratio [HR] 0.166 ; 95% CI 0.056 to 0.492; p = 0.01). Conclusions Monitored NSVT bouts in ICD recordings may serve as a predictor of future HF hospitalizations in ICD recipients with HF suggesting optimization of therapeutic modalities in these patients along with a close supervision in the clinical setting.