Mesut Demir

Clinical characteristics influence left and right ventricular diastolic function in healthy individuals.

The aim of this study was to determine whether clinical characteristics have an influence on left (LV) and right ventricular (RV) diastolic function indices measured by echocardiography in healthy individuals. Five hundred and three volunteers (253 women and 250 men) aged 18-66 years (mean 36.9 ±11.9) who were normotensive and free of clinically apparent heart disease were included in the study. Mitral and tricuspid peak E wave and A wave velocities, E/A ratio, deceleration time (DT) of the E wave, and left ventricular isovolumetric relaxation time (IVRT) were evaluated as left and right ventricular diastolic function indices. In order to determine the effects of age, gender, body surface area (BSA), waist/hip ratio (WHR), and heart rate (HR) on left and right ventricular diastolic function indices Students t test and correlation and linear regression analysis were used. IVRT and deceleration time of the mitral E wave (DTm) were significantly longer in men. Mitral and tricuspid A wave velocities, tricuspid E/A ratio, and decel eration time of the tricuspid E wave (DTt) were similar in both genders. Mitral and tricuspid E wave velocities and mitral E/A ratio were greater in women. Mitral E wave velocity and IVRT mostly correlated with WHR. Age was found to be the most important factor affecting mitral A wave velocity, DTm, E/A ratio, and right ventricular diastolic function indices. This study shows that age, heart rate, body surface area, and waist/hip ratio have important correlations with Doppler echocardiographic diastolic indices in normal individuals and should be consid ered in the evaluation of LV and RV diastolic function.

The effect of early statin treatment on inflammation and cardiac events in acute coronary syndrome patients with low-density lipoprotein cholesterol.

We investigated the effects of atorvastatin on inflammation and cardiac events during the inpatient period and initial 6-month follow-up in acute coronary syndrome (ACS) patients with low low-density lipoprotein (LDL) cholesterol level. One hundred and twelve consecutive ACS patients with LDL cholesterol less than 100 mg/dl were included in the study (mean 78.2 ± 12.3 mg/dl). While 70 randomly selected patients received a dose of 40 mg atorvastatin within the first 24 h on top of their standard treatment as the atorvastatin group, the remaining 42 patients considered as the control group were given the standard treatment only, i.e., without any lipid-lowering drug therapy. Lipid profile, high-sensitivity C-reactive protein (hsCRP), and plasma amyloid A (SAA) levels were measured in all patients within the first 24 h of chest pain, on the 5th day, and in the 6th month. During the inpatient period and subsequent 6-month follow-up, all episodes of angina, reinfarction, revascularization, heart failure, rehospitalization, cardiac mortality, and total number of cardiac events were recorded. In the atorvastatin group, hsCRP and SAA values on the 5th day and in the 6th month compared to the first 24 h were significantly lower than those of the control group (P < 0.0001). Mean LDL cholesterol level was significantly decreased in the atorvastatin group (55.7 ± 17.7 mg/dl), but there was no significant change in the control group at the 6th month. The frequency of heart failure during the inpatient period and angina, unstable angina pectoris, heart failure, and revascularization in the first 6 months were also significantly reduced in the atorvastatin group. Atorvastatin started in the first 24 h reduces inflammation and improves the prognosis during both the inpatient period and the first 6 months of clinical follow-up in ACS patients with low LDL cholesterol levels.

Cardiac troponin T as a prognostic marker in patients with heart failure : a 3-year outcome study.

Cardiac troponin T (cTnT), a highly sensitive and specific indicator of myocardial cell death, may be elevated in congestive heart failure (CHF). The aims of this study were to test the hypothesis that decompensated CHF may be associated with an increase in cTnT release and to correlate between cTnT levels and patient outcomes. The authors studied 55 patients aged between 38 and 86 years (30 women and 25 men) who were hospitalized for CHF. Left ventricular ejection fraction (EF) was calculated by using modified Simpsons rule by echocardiography. cTnT levels were assessed. Troponin T ≥0.1 ng/mL was considered as positive. All patients were contacted by phone annually during the next 3 years, and their history of subsequent hospital admissions and current health status were recorded. cTnT was negative in 44 (80%) and positive in 11 (20%) patients. EF was significantly lower and NYHA was higher in cTnT-positive patients. During the 3-year follow-up period, 25 patients died from CHF. The mortality rate was 8/11 (72.7%) among cTnT-positive patients, whereas the mortality rate was 17/44 (38.6%) among cTnT-negative patients. There were significant relationships among positivity of cTnT, NYHA, EF, and mortality rate. Multivariate regression analysis yielded an independent relationship between positivity of cTnT, NYHA classification, and mortality rate. The percent of hospital admissions due to CHF was also higher in patients with cTnT positive (63.6% versus, 27.3%, p <0.05). In conclusion, this study shows that cTnT positivity is an independent risk factor in predicting the long-term mortality and morbidity rate in patients with CHF. Patients with worsening CHF may possibly be identified early on the basis of their elevated serum cTnT levels.

The Presence of a Calcific Plaque in the Common Carotid Artery as a Predictor of Coronary Atherosclerosis

Many contradictory reports have been published investigating the relationship between coronary artery disease (CAD) and the increased intima-media thickness (IMT) in the common carotid artery (CCA). However, only a limited number of studies evaluate the relationship between CAD and CCA disease as reflected by both the plaque morphology (fibrous and calcific plaques) and IMT. We have studied the associations between CAD and the wall morphology of CCA by B-mode ultrasound (US). One hundred and forty-four subjects, whose angiography was planned on the basis of suspected CAD, were included into the study. The patients were divided into 4 groups on the basis of B-mode US findings; Group I: normal, Group II: increased IMT (IMT ≥ 0.8 mm and plaque absent), Group III: fibrous plaque, Group IV: calcific plaque. Coronary artery disease was diagnosed in 63 patients. A statistically significant correlation was found between CAD and CCA wall morphology (r =0.42, CI (95%) = 0.30-0.51, p<0.001). Positive predictive values were 45.0%, 48.4%, and 75.0% in patients with increased IMT, fibrous plaque, and calcific plaque, respectively. None of the women with normal CCA wall morphology had significant coronary artery lesion. With respect to the normal group, the risk for CAD increased by 4.3 fold with the existence of fibrous plaque (p=0.02) and by 9.9 fold with the existence of calcific plaque (p<0.001). It has been shown that the CCA wall morphology determined by B-mode US is correlated with CAD in patients with chest pain, and the presence of calcific plaque is a better predictor for CAD than that of fibrous plaque and increased IMT. Women with chest pain and normal CCA wall morphology may not need coronary angiography.

Effects of atorvastatin on lipid profile and coagulation parameters

Abstract Background: Hypercholesterolemia is an important risk factor for coronary artery disease (CAD) and is associated with impaired endothelial function, hypercoagulability, and increased platelet activation. The ability of statins to reduce the mortality and morbidity associated with CAD may not be due entirely to their lipid-lowering effects. Objective: The aim of this study was to determine the effects of atorvastatin on lipid profile and coagulation parameters. Methods: Adults with documented hypercholesterolemia who did not respond to dietary intervention alone and had not been treated pharmacologically were enrolled. In accordance with the criteria of the American Heart Association guidelines, patients began therapy with atorvastatin 10 mg/d. Total cholesterol (TC), low-density and high-density lipoprotein cholesterol (LDL-C and HDL-C), triglycerides (TG), fibrinogen, prothrombin time (PT), activated partial thromboplastin time (aPTT), clot retraction time (CRT), and tissue plasminogen activator (t-PA) levels were determined at baseline and at week 12 of treatment. Results: A total of 8 men and 11 women (mean age, 57.2 ± 10.0 years; range, 43–77 years) were included in the study. Significant reductions from baseline in TC (baseline, 259.5 ± 29.3 mg/dL; week 12, 186.2 ± 39.9 mg/dL; −28%) and LDL-C (baseline, 177.5 ± 24.5 mg/dL; week 12, 115.6 ± 35.0 mg/dL; −34%) were observed at the end of the study ( P P > 0.05). CRT was shortened but remained within the normal range ( P P Conclusions: The data from this study suggest that treatment with atorvastatin decreases t-PA levels and CRT as well as lipid levels. The reduction in t-PA and CRT may be a result of improvements in previously impaired endothelial function and coagulation.

Systolic Tissue Velocity Is a Useful Echocardiographic Parameter in Assessment of Left Atrial Appendage Function in Patients with Mitral Stenosis

Background: The incidence of thromboembolism remains high in patients with mitral stenosis (MS). The left atrial appendage (LAA) is a potential site for development of thrombus and LAA dysfunction is an independent predictor of thromboembolism. The LAA dysfunction is represented by reduced LAA late emptying velocity. But the magnitude of LAA flow velocities is dependent on acute changes in loading conditions. Aim: To investigate the value of the LAA tissue velocities obtained by tissue Doppler imaging (TDI) in assessment of LAA function in MS patients with and without thromboembolic events. Methods: The study population consisted of 98 isolated MS patients of 32 age and sex‐matched healthy controls. All subjects underwent transesophageal echocardiography (TEE). LAA late peak emptying (LAAEV) and filling (LAAFV) flow velocities were recorded. LAA peak late tissue systolic (LSV) and diastolic (LDV) tissue velocities by TDI were measured. The patients were divided into three groups as Group I (n = 38, sinus rhythm and LAAEV ≥ 25 cm/s), Group II (n = 26, sinus rhythm and LAAEV < 25 cm/s), and Group III (n = 34, atrial fibrillation). Results: Twenty‐one patients had thromboembolic events. LAAEV, LAAFV, LSV, and LDV were significantly reduced in patients with embolic events. Spontaneous echo contrast (SEC) density was strongly negative correlated with LSV, whereas weakly negative correlated with LAAEV. Multivariate regression analysis showed that LSV and the presence of SEC were independently associated with embolic events. Conclusion: LSV seems more reliable and useful parameter in evaluating LAA function. LAA function is more depressed among patients with embolic events.

Tissue Doppler is a More Reliable Method in Early Detection of Cardiac Dysfunction in Patients with AA Amyloidosis

Objective. Cardiac deposition of AA amyloidosis may result in increasing left ventricular mass and systolic and diastolic dysfunction (DD). The aim of this study was to investigate the left ventricular systolic and diastolic functions by both tissue Doppler imaging (TDI) and pulsed wave Doppler echocardiography (PWD) in patients with AA amyloidosis without congestive heart failure symptoms or arrthymia. Methods and Results. Twenty-four patients with AA amyloidosis without congestive heart failure symptoms or arrthymia (15 men and nine women; mean age 44.3 ± 16.7 years) and 25 healthy subjects (19 men and six women; mean age 43.1 ± 9.2 years) as controls were included in the study. M-mode, two-dimensional, PWD, and TDI were performed. Peak transmitral filling velocity (E wave), peak transmitral atrial filling velocity (A wave), deceleration time, and isovolumic relaxation time were measured by PWD recordings. Peak myocardial systolic velocity (Sm), peak myocardial early (Em), and late diastolic velocities (Am) were also recorded by TDI. E/A ratio less than one was accepted as DD for both methods. Ejection fraction (EF) was calculated by Teicholtz method. The subjects were divided into three groups as follows: healthy controls (group 1), patients without DD (group 2), and patients with DD (group 3) according to the PWD findings. PWD echocardiography showed that DD was present in 50% of the patients, whereas TDI showed DD in 66% of such cases. In subgroup analysis, Sm wave as a systolic function index was lower in group 3 than in groups 1 and 2, whereas mean EF values were similar in all groups. Conclusion. Although AA amyloidosis uncommonly causes cardiac symptoms and findings, according to our results, patients with AA amyloidosis may have systolic and diastolic dysfunction eventhough they are asymptomatic. Also, tissue Doppler imaging is a more reliable method in the early detection of cardiac dysfunction in such patients.

Mitral annular calcification and aortic valve calcification may help in predicting significant coronary artery disease.

Mitral annular calcification (MAC) and aortic valve calcification (AVC) are manifestations of atherosclerosis. To determine whether mitral annular calcification and aortic valve calcification detected by transthoracic echocardiography (TTE) might help in predicting significant coronary artery disease (CAD), 123 patients with significant CAD and 93 patients without CAD detected by coronary angiography were investigated. MAC and AVC identified CAD with a sensitivity and specificity of 60.2%, 55.9% and 74.8%, 52.7%, respectively, and with a negative and a positive predictive values of 51.5%, 64.3% and 61.3% and 67.6%, respectively. The positive predictive value of MAC was greater than gender, hypertension, and hypercholesterolemia. AVC showed a positive predictive value greater than gender, hypertension, family history, and hypercho lesterolemia. The negative predictive values of MAC and AVC for CAD were greater than those of all risk factors except diabetes mellitus. In conclusion, presence of MAC and AVC on TTE may help in predicting CAD and should be added to conventional risk factors. Absence of MVC and AVC is a stronger predictor for absence of CAD than all conventional risk factors, except diabetes mellitus. Patients with MAC and AVC should be taken into consideration for the presence of significant CAD and thereby for diagnostic and therapeutic interventions in order to improve the prognosis.

Ultrasound Accelerated Thrombolysis May Be an Effective and Safe Treatment Modality for Intermediate Risk/Submassive Pulmonary Embolism

Pulmonary embolism (PE) is a potentially life-threatening condition and the fact that 90% of PE originate from lower limb veins highlights the significance of early detection and treatment of deep vein thrombosis. Massive/high risk PE involving circulatory collapse or systemic arterial hypotension is associated with an early mortality rate of approximately 50%, in part from right ventricular (RV) failure. Intermediate risk/submassive PE, on the other hand, is defined as PE-related RV dysfunction, troponin and/or B-type natriuretic peptide elevation despite normal arterial pressure. Without prompt treatment, patients with intermediate risk PE may progress to the massive category with a potentially fatal outcome. In patients with PE and right ventricular dysfunction (RVD), in hospital mortality ranges from 5% to 17%, significantly higher than in patients without RVD.

Comparison of single-dose and repeated levosimendan infusion in patients with acute exacerbation of advanced heart failure

Background Levosimendan (LS) is a novel inodilator that improves cardiac performance, central hemodynamics, and symptoms of patients with decompensated chronic heart failure. The aim of this study was to compare the effects of single and repeated LS infusion on left ventricular performance, biomarkers, and neurohormonal activation in patients with acute heart failure. Material/Methods Twenty-nine consecutive patients with acute exacerbation of advanced heart failure were included in this study. LS was initiated as a bolus of 6 μg/kg followed by a continuous infusion of 0.1 μg/kg/min for 24 hours in both groups who received intravenous single and repeated (baseline and at 1 and 3 months) treatment. Physical examination, echocardiography, and biochemical tests (brain natriuretic peptide, tumour necrosis factor-α, interleukin-1β, 2, and 6) were performed before treatment and on 3 day of the treatment. The last evaluation was performed at 6 month after the baseline treatment. Results Twenty male and 9 female patients with mean age of 60.2±7.4 years were included in this study. A significant improvement in New York Heart Association functional status and myocardial performance index was detected only in the repeated LS treated patients at 6 month compared to the pretreatment status (p=0.03 and p<0.001; respectively). In addition, a significant decrease in brain natriuretic peptide (p<0.01) and plasma interleukin-6 (p=0.05) levels were also achieved only in patients who were given repeated LS. Conclusions Our study showed that repeated LS treatment is more effective compared to the single dose LS treatment in improving clinical status, hemodynamic and laboratory parameters in patients with acute exacerbation of advanced heart failure.